Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility was found to have a medication error rate of 18.18% during medication administration observations, with 6 errors identified out of 33 opportunities involving three residents. For one resident with diabetes, an LVN failed to prime the insulin pen before administering a 40-unit dose of insulin degludec, despite facility policy and manufacturer instructions requiring priming to ensure accurate dosing. The LVN acknowledged the omission during an interview, and both the DON and consultant pharmacist confirmed that priming is required before each use. Another resident was prescribed fluticasone nasal spray with instructions to administer two sprays in each nostril daily. During observation, an LVN administered only one spray per nostril. Upon review of the physician's order and facility policy, the LVN confirmed the error and acknowledged the correct dose should have been given as ordered. A third resident, who received medications via a gastrostomy tube, was administered four different crushed medications combined together in a single dose, contrary to facility policy. The RN responsible for the administration admitted that each medication should have been crushed and administered separately with appropriate flushing between medications. The DON and consultant pharmacist both confirmed that medications should not be mixed together for enteral administration, and the facility's policy requires separate administration and flushing.