Significant Medication Error Due to Improper Administration of Time-Release Capsule
Penalty
Summary
A deficiency occurred when facility staff failed to ensure a resident was free from significant medication errors. Specifically, a Licensed Vocational Nurse (LVN) was observed opening a Macrobid (nitrofurantoin macrocrystals) 100 mg oral capsule, pouring its contents into a medication cup, and mixing it with applesauce prior to administration. This action disrupted the time-release mechanism of the medication, which was intended to be delivered in a specific manner for therapeutic effectiveness. The LVN acknowledged that opening capsules should only be done after verification with a pharmacist, as some capsules are not meant to be opened due to potential changes in drug efficacy and safety. The resident involved had multiple diagnoses, including rheumatoid arthritis, diabetes mellitus, and encephalopathy, and was assessed as having moderately impaired cognition. The resident required assistance with activities of daily living and supervision with mobility. The medication order for Macrobid specified administration by mouth, but did not indicate that the capsule should be opened or mixed with food. The Medication Administration Record confirmed that the resident received the medication in this altered form. Interviews with the LVN and the Director of Nursing (DON) confirmed that facility policy required clarification with a pharmacist before altering any capsule medication, especially antibiotics that are often time-released. The DON emphasized the importance of maintaining the intended formulation to ensure proper absorption and effectiveness. Review of facility policy and job descriptions further supported that medications were to be administered as prescribed and in accordance with regulatory guidelines.