Medication Error Rate Exceeds Acceptable Threshold Due to Improper Crushing of Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required. During medication administration observations, two errors were identified out of twenty-five opportunities, resulting in an 8.0% error rate. In one instance, a registered nurse crushed and administered gabapentin, which is listed by the facility and the Institute of Safe Medication Practices (ISMP) as a medication that should not be crushed. In another instance, the same nurse crushed and administered nifedipine extended-release, despite the medication administration history specifically stating 'DO NOT CRUSH' as a special instruction. The nurse also crushed other medications for the same resident, including calcium carbonate, buspirone, and vitamin D3. Interviews revealed that the nurse was unaware of where to find the facility's list of medications that should not be crushed. The facility's policy on medication administration requires staff to follow physician orders, pharmacy instructions, and facility policy, including not crushing long-acting or enteric-coated dosage forms unless specifically ordered by a physician. The Director of Nursing confirmed that staff are expected to be familiar with these requirements. The failure to adhere to these protocols directly contributed to the identified medication errors.