Medication Error Rate Exceeds 5% Due to Incomplete Administration via GT
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 5.13%. During a medication administration observation, one licensed nurse (LVN 1) did not administer the complete dose of two medications—zinc and vitamin D3—to a resident receiving medications via a gastrostomy tube (GT). After administration, significant residue of these medications was found in the medication cups, indicating that the full prescribed doses were not delivered as ordered. The facility's policies and procedures require that medications be fully administered according to prescriber orders and that medications given via enteral tube be properly diluted and mixed to ensure complete dosing. Interviews with LVN 1, the Assistant Director of Nursing (ADON), and other facility leadership confirmed that the expected practice is to add water and thoroughly mix any medication residue to ensure the entire dose is administered. LVN 1 acknowledged the failure to do so during the observed medication pass. The incident involved a resident with multiple medical conditions, including diabetes, hypertension, and the need for enteral feeding, who was prescribed several medications and supplements. The incomplete administration of zinc and vitamin D3 was directly observed and verified by facility staff.