Medication Error Rate Exceeds Acceptable Threshold During PEG Tube Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by 9 medication errors out of 44 opportunities during a medication pass observation, resulting in a 20.45% error rate. During the observed medication administration for one resident with a PEG/feeding tube, an LPN prepared and administered multiple oral medications by crushing them together and dissolving them in water, rather than administering each medication separately as required for PEG tube administration. The LPN also prepared and mixed Valproic Acid separately but ultimately administered all medications at the same time through the feeding tube. The LPN confirmed during an interview that all medications were administered simultaneously, not one at a time. The incident was discussed with the nursing home administrator and the director of nursing, and the findings were reviewed during the exit conference. The report does not mention any corrective actions or follow-up steps taken after the incident.