Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with an observed error rate of 5.88%. One incident involved an LPN administering a heparin flush to a resident using a 5-milliliter dose instead of the 10-milliliter dose ordered by the physician. The LPN stated that their usual practice was to perform a heparin flush before and after medication administration, but the physician order specified a 10-milliliter flush every shift. The Director of Nursing confirmed that staff are expected to follow physician orders and the SASH protocol, and the facility's competency checklist also required adherence to proper dosage and administration guidelines. Another incident involved an LPN preparing to crush and administer a delayed-release omeprazole tablet via a gastric tube for a resident, contrary to the physician's order, which specified an oral capsule to be given via G-tube. The LPN acknowledged that delayed-release medications should not be given via G-tube and indicated the need to clarify the order with the provider. The Director of Nursing reiterated that nurses should clarify any questionable orders before administration, and the facility's policy stated that certain medications, including delayed-release forms, should not be crushed and administered via enteral feeding tubes.