Medication Administration Errors Due to Failure to Follow Physician Orders
Penalty
Summary
The facility failed to follow physician orders for medication administration for two of four sampled residents during a medication administration observation, resulting in a medication error rate of 7.41%. For one resident with COPD and a BIMS score indicating cognitive intactness, a LPN administered inhaled medications via nebulizer but did not instruct the resident to rinse her mouth after treatment, as specifically required by the physician's order for Budesonide. The omission was confirmed by the Director of Nursing upon review of the order and observation of the medication pass. In a separate incident, another cognitively intact resident was ordered to receive Sodium Zirconium Cyclosilicate mixed with 8 ounces of water for hyperkalemia. The LPN administering the medication used a cup that only held 4 to 5 ounces, as the facility had run out of 8-ounce cups and had not yet distributed newly received stock. Multiple staff confirmed that only smaller cups were available on the medication carts at the time, and the Central Supply clerk acknowledged not considering alternative sources for the correct cup size. The DON verified that the medication was not mixed according to the physician's order.