Medication Administration Errors and Failure to Follow Orders
Penalty
Summary
The facility failed to ensure medications were administered as ordered and in accordance with pharmacy instructions, resulting in a medication error rate of 20% (five errors out of 25 opportunities). In one instance, a registered nurse did not follow the pharmacy label instructions to turn a Cyclosporine eye drop vial upside down several times before administration and used a 5% menthol gel instead of the prescribed 4% menthol gel for a resident's knee pain, without updating the medication order. The nurse confirmed not realizing the need to agitate the Cyclosporine vial and acknowledged the substitution of the gel strength without physician authorization. In another case, a registered nurse administered a resident's Keppra and Coreg significantly later than scheduled and withheld a scheduled dose of Novolog insulin based on the resident's blood glucose, despite lacking physician-ordered parameters to do so. The nurse did not notify the physician of the late administration or the withheld insulin dose, nor was this documented in the resident's medical record. The Director of Nursing confirmed that such deviations from scheduled medication times and withholding of medications without orders require physician notification and documentation, which did not occur in these instances.