Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to properly administer medications as ordered for three residents, resulting in a medication error rate of 12%, which exceeds the acceptable threshold. In one instance, a registered nurse administered Novolin Regular Insulin to a resident after the resident had already eaten lunch, rather than prior to the meal as required by the physician's sliding scale order. The nurse confirmed that the blood glucose was checked and insulin was given after the meal, contrary to the prescribed protocol. In another case, a nurse administered Metoprolol Tartrate to a resident despite the resident's heart rate being below the physician-ordered parameter of 90 beats per minute. The nurse acknowledged that the medication should not have been given under these circumstances. Additionally, a third resident received Carvedilol without the nurse checking the required blood pressure and heart rate prior to administration, as specified in the physician's order. The nurse admitted to not obtaining these vital signs before giving the medication. The facility's policy requires checking the MAR, verifying orders, and obtaining any necessary monitoring parameters before administering medications.