Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 23.08% error rate observed during medication administration for four residents. For one resident with dysphagia, a nurse administered two medications via G-tube that were ordered to be given orally with applesauce. The nurse stated the resident preferred G-tube administration due to difficulty swallowing, but the physician's orders had not been updated to reflect this route. The Director of Nursing confirmed that nurses are expected to follow the prescribed route and contact the provider for any necessary changes before administration. Another resident with dementia, hemiplegia, and diabetes received a subcutaneous insulin injection in the deltoid muscle area, where there was no visible adipose tissue. The nurse administered the injection at a 90-degree angle into the deltoid, which is not a recommended site for subcutaneous injections due to lack of fatty tissue. Facility reference materials and manufacturer guidelines specify that subcutaneous injections should be given in areas with sufficient adipose tissue, such as the outer arm, thigh, abdomen, hips, buttocks, or upper back. A third resident was administered a group of oral medications mixed in applesauce, including a blood pressure medication with a hold parameter for systolic blood pressure below 110. The nurse initially prepared to administer the medication despite a blood pressure reading of 109, only discarding what was believed to be the correct tablet after being prompted. However, the discarded tablet did not match the appearance of the intended medication, raising concerns that the wrong medication may have been withheld or administered. Additionally, a fourth resident was given chewable medications to swallow whole without being instructed to chew them, contrary to both physician orders and facility policy.