Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors observing an error rate of 25.81% during medication administration for four out of six residents. Multiple instances were documented where medications were not administered according to prescriber orders or manufacturer specifications. For example, a nurse administered chewable aspirin to a resident without instructing them to chew it, and provided only 5 oz of water instead of the required 8 oz, despite the order specifying the medication should be chewed and taken with food or a full glass of water or milk. Additionally, omeprazole was not given before eating as directed by the manufacturer. Another resident received medications including chewable aspirin, metoprolol, and potassium chloride with only 5 oz of water and no food, even though the orders and manufacturer instructions required administration with food and a full glass of water. The nurse confirmed that the resident had eaten breakfast earlier, but did not provide food or the correct amount of water at the time of administration. The pharmacy consultant emphasized the importance of following these instructions to ensure proper absorption and minimize gastrointestinal irritation. Further observations included a nurse administering tramadol for severe pain when the order specified it was for moderate pain only, and giving carvedilol without food, contrary to the order and manufacturer instructions. Another resident was given allopurinol without food or the required amount of water, despite orders to administer with both. The facility's policy required medications to be administered as prescribed and in accordance with manufacturer specifications, but these procedures were not followed during the observed medication passes.
Plan Of Correction
How the corrective action(s) will be monitored to ensure the practice will not recur: DON/Designee will conduct weekly medication administration audits. Any issues identified will be reported to the Director of Nursing and immediately corrected. This plan of correction has been integrated into the QA program, and the results of these audits will be reviewed quarterly as needed until substantial compliance is achieved. Plan of Correction completion date: 6.30.25 F 759 F 759 F 759 F 759 F 759