Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 36% based on 9 errors out of 25 observed medication administration opportunities. During medication administration, a licensed nurse prepared and handed a resident a cup containing nine different medications, including Entresto, Eliquis, Allopurinol, Florastor, Metoprolol, Jardiance, Eplerenone, Torsemide, and Oxycodone. The nurse asked the resident to rate their pain level and then left the room without observing the resident ingest the medications. There was no documentation of a physician's order or a self-administration assessment authorizing the resident to self-administer or be left with medications. Interviews with facility staff revealed that the nurse believed the resident was independent and routinely took medications without supervision, but the Director of Nursing confirmed that nurses should not leave medications with residents and must observe ingestion. Review of the resident's medication record showed discrepancies in administration times, and facility policies required documentation of medication administration and an interdisciplinary team determination for self-administration. The facility was unable to provide evidence of compliance with these requirements for the resident involved.