Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported rate of 15.38 percent based on 27 observed opportunities and four medication errors involving three residents. One resident had their blood glucose checked after beginning a meal, contrary to prescriber orders requiring assessment before meals. This resulted in an inaccurate blood glucose reading and subsequent insulin administration based on a non-fasting value. Both the nurse and the Director of Nursing confirmed that the timing of the blood glucose check did not comply with the prescriber's instructions and could affect insulin dosing. Another resident experienced two errors: their blood glucose was also checked after eating, and a phosphate-binding medication (calcium acetate) was administered after the meal instead of with the meal as ordered. The resident confirmed having already eaten prior to the medication administration. The nurse acknowledged both errors, and the Director of Nursing stated that the medication would not be effective if not given as ordered. Manufacturer instructions for the medication also specify administration with meals to ensure efficacy. A third resident was administered a different phosphate binder (sevelamer carbonate) instead of the prescribed sevelamer hydrochloride, and the medication was not given in accordance with the prescriber's order. The nurse recognized the error and noted the importance of administering the correct medication for the resident's specific diagnosis. The facility's policy requires verification of the five rights of medication administration and adherence to prescriber orders, which was not followed in these instances.