Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 12% based on 3 errors out of 25 observed opportunities. One incident involved a registered nurse preparing Levothyroxine for a resident, during which the tablet was dropped onto the top of a medication cart that was acknowledged as dirty and not disinfected. The nurse picked up the tablet with gloved hands, without performing hand hygiene, and administered it to the resident instead of discarding it and using a new tablet, as required. Another incident involved a nurse preparing Diclofenac Sodium (Voltaren) gel for a resident's knees without using the required dosing card to measure the correct 4-gram dose. The nurse was unaware of the dosing card's existence and could not confirm the correct amount was administered. A third incident involved the administration of fast-acting insulin using a Novolog Flexpen, where the nurse changed the needle after priming and did not follow the manufacturer's instructions to keep the needle in the skin for six seconds after the dose counter reached zero, potentially resulting in an incomplete dose. These actions were observed and confirmed through interviews and record reviews.