Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy, resulting in a calculated error rate of 15.38% with 4 errors out of 26 opportunities. This deficiency was identified through observation, interviews, and record reviews, and involved two residents during the medication administration task. The facility's policy required medications to be administered as prescribed, following the five rights of medication administration, and within specified timeframes. For one resident with a history of gastrointestinal hemorrhage and constipation, a medication error occurred when an LPN administered polyethylene glycol 3350 powder without properly measuring the dose using the provided measurement lines in the bottle cap, as required by manufacturer instructions and facility policy. The LPN admitted to not knowing the correct method for measuring the medication, and interviews with other nursing staff and the Director of Health Services confirmed that the medication should be measured accurately using the cap's internal lines and checked at eye level. Another resident, admitted with hypokalemia and hypothyroidism, received multiple medications, including levothyroxine, calcium carbonate, ferrous gluconate, and potassium chloride, all administered together in one cup and without food, despite specific orders and manufacturer instructions. Levothyroxine was supposed to be given on an empty stomach and separately from calcium and iron supplements, while potassium chloride was to be given with food. The LPN confirmed that the medications were not administered according to these requirements, and this was corroborated by interviews with other nursing staff, the Director of Health Services, and the facility pharmacist.