Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and manufacturer recommendations, resulting in a medication error rate of 13.64 percent. During medication administration observations, staff were found to have administered medications incorrectly on multiple occasions. For example, one nurse administered an over-the-counter calcium with vitamin D3 supplement instead of the prescribed Citrical D3 Plus Mg-Zn-copper-manganese supplement, and both the nurse and an APRN confirmed that the two products were not interchangeable. In another instance, a nurse failed to prime an insulin pen before administering Humulin R insulin, contrary to both manufacturer instructions and facility policy, and only held the pen in place for two seconds instead of the required ten seconds. Additionally, medications such as Eliquis and Nystatin were administered outside of the scheduled times as ordered by the physician, with staff acknowledging the late administration due to being delayed by other resident care needs. Further errors included the administration of cetirizine to a resident who had an order for loratadine, resulting in the resident receiving two different allergy medications. The nurse involved confirmed the error and stated that there was no over-the-counter loratadine available, leading to the substitution. The Director of Health Services confirmed expectations for proper medication administration, including priming insulin pens and adhering to scheduled medication times.