Medication Administration Error Rate Exceeds 5% Due to Improper Insulin Priming and Unobserved Medication Ingestion
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, resulting in a 7.69% error rate based on 2 errors in 26 observed opportunities. In one instance, a registered nurse (RN) was observed preparing an insulin pen for a resident but did not properly prime the pen according to manufacturer instructions. The RN primed the pen while holding it horizontally with the needle cover on and did not confirm that insulin was visible at the tip of the needle, nor did he repeat the priming process as required if insulin was not observed. Manufacturer instructions specify that the pen should be held with the needle pointing up, and insulin should be visible at the tip after priming, with steps to repeat if necessary. In another instance, the same RN left a prepared dose of Miralax on a resident's over-bed table and exited the room without confirming whether the resident was able to self-administer medications. The RN was unable to confirm the resident's ability to self-administer and stated he would return to observe the medication being taken. Facility policy requires that medications are administered at the time they are prepared and that staff observe residents to ensure the medication is completely ingested. These actions resulted in medication administration errors for two residents.