Medication Administration Errors Exceeding Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during medication administration, resulting in an observed error rate of 11.11%. For one resident with a diagnosis of dysphagia and schizophrenia, a Licensed Vocational Nurse (LVN) crushed a delayed release divalproex tablet and a lorazepam tablet, then mixed and administered them together with applesauce. The physician's order specified divalproex as a delayed release tablet, which should not be crushed, and the facility's policy also indicated that timed release tablets must not be crushed. The LVN acknowledged after the fact that the medication should not have been crushed and that the two medications should have been administered separately to identify any intolerance to either medication. Additionally, the same LVN administered hydrocodone-acetaminophen to another resident for pain levels that did not meet the physician's prescribed parameters. The order specified that hydrocodone-acetaminophen was to be given only for severe pain (pain level 8-10), but the medication was administered multiple times for moderate pain levels (pain levels 4-7). The Medication Administration Record (MAR) review revealed at least 15 instances over three months where the medication was given outside the prescribed pain parameters. The LVN stated that she administered the medication for a pain level of 6 because the resident was supposed to receive therapy, despite the order's requirements. Interviews with the Director of Nursing (DON) confirmed that the medications were not administered according to physician orders and facility policy. The DON stated that delayed release divalproex should not have been crushed and that hydrocodone-acetaminophen should only have been given for severe pain as ordered. Facility policy required medications to be administered as prescribed and for staff to verify the right medication, dose, and time before administration. These failures resulted in a medication error rate exceeding the regulatory threshold.