Medication Error Rate Exceeds Acceptable Threshold Due to Improper Crushing of Medications
Penalty
Summary
Facility B failed to maintain a medication error rate below five percent, as required, during a medication administration observation. Out of 25 opportunities for error, three medication errors were identified, resulting in a medication error rate of 12%. Specifically, a registered nurse crushed and administered Potassium Chloride Extended Release (ER) to a resident with hypokalemia, ferrous sulfate to a resident with iron deficiency anemia, and gabapentin to a resident with peripheral neuropathy. These medications were crushed and mixed with applesauce before administration. Interviews with nursing staff and the facility administrator confirmed that these medications should not have been crushed, as per manufacturer recommendations and facility policy. The facility's policy and the pharmaceutical guidelines for each medication explicitly state that Potassium Chloride ER, ferrous sulfate, and gabapentin should not be crushed due to the risk of altering their intended release and absorption. The actions observed were not in accordance with manufacturer specifications or accepted professional standards.