Medication Error Rate Exceeds 5% Due to Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by federal regulations, resulting in an observed error rate of 8% out of 25 opportunities. During medication administration, an LPN was observed crushing and administering two extended-release medications to a resident, despite both medications being contraindicated for crushing. The physician's order allowed for medications to be crushed or diluted unless contraindicated, but the extended-release formulations specifically should not have been altered in this way, as confirmed by reference sources and the facility's consultant pharmacist. The facility's policies require medications to be administered according to prescriber orders and for staff to consult with a physician or pharmacist if there are concerns about medication appropriateness or potential adverse consequences. Both the consultant pharmacist and the Director of Nursing confirmed that the extended-release medications should not have been crushed and that alternative formulations or orders should have been sought. The incident was identified during an unannounced recertification survey, and the deficiency was based on direct observation, record review, and staff interviews.
Plan Of Correction
F759-Free of Medication Error Rate of 5% or More (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On Staff A was educated regarding medication administration and the "Do not Crush" list on medication cart. On Resident #22 was assessed by a licensed nurse with no negative findings. MD was notified of medication error with orders received to change the form of the 2 identified medications. Started treatment on . (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On Audit was completed by Director of Nursing/designee on current residents to identify if medications needed to be crushed. Any identified meds were changed to the appropriate form. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , Current Licensed Nurses will be educated on the components of F759 with an emphasis on being aware of what medications can be crushed and which medications can not be crushed as well as overall medication administration practices by the DON/Designee. Newly hired licensed Nurses will be educated on the components of F759 with an emphasis on being aware of what medications can be crushed and which medications can not be crushed as well as overall medication administration practices by the DON/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct observations of medication administration 3x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that licensed Nurses are administering medications properly. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.