Medication Administration Errors Involving Extended-Release and Meal-Timed Medications
Penalty
Summary
The facility failed to prevent medication errors during medication administration for two residents, resulting in a medication error rate of 7.14%. For one resident with a history of anemia, atrial fibrillation, heart failure, hypertension, hyponatremia, hyperlipidemia, non-Alzheimer's dementia, and malnutrition, and who had a feeding tube, a licensed practical nurse crushed all tablets, including potassium chloride extended-release, before administering them via PEG-tube. The provider order specified that the potassium chloride extended-release should be dissolved in water, not crushed. The nurse confirmed knowledge of which medications could or could not be crushed but still crushed the extended-release tablet. The director of nursing and consultant pharmacist both confirmed that crushing extended-release potassium chloride was not appropriate, as it compromised the medication's intended release mechanism. For another resident with benign prostatic hyperplasia and kidney disease, a registered nurse administered tamsulosin hydrochloride capsules while the resident was still eating breakfast, despite provider orders specifying the medication should be given after a meal. The nurse stated that the resident preferred to take all medications at the same time and planned to update the provider and care plan accordingly. The consultant pharmacist explained that administering tamsulosin during a meal, rather than after, could decrease the medication's effectiveness. The facility's medication administration policy required staff to follow provider orders and manufacturer specifications, which was not done in these instances.