Medication Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5%, as required, resulting in a 20% error rate based on 5 errors out of 25 observed opportunities. Staff administered incorrect medication doses and wrong medications to several residents. Specifically, one resident with severe cognitive impairment was prescribed folic acid 1 mg daily but was given 800 mcg instead, as the correct dose was not available. Another resident with kidney failure and iron deficiency, who was ordered folic acid 400 mcg daily, received 800 mcg. Additionally, a resident with diabetes and vitamin D deficiency was ordered ferrous sulfate 325 mg daily but was given ferrous gluconate 27 mg instead. Staff interviews confirmed that medications and doses were not administered as ordered, and staff acknowledged that they should have sought clarification from the physician or ensured the correct medication was available before administration. The DON and Administrator both stated that staff should follow physician orders and not substitute medications or doses. The facility's policy required adherence to the five rights of medication administration, including the right drug and right dose, and staff failed to comply with these requirements in the observed cases. Further deficiencies were observed in the administration of insulin using prefilled pens. Two residents with diabetes were administered insulin without the required priming of the pen before each use, contrary to manufacturer guidelines and facility policy. Staff interviews revealed a lack of knowledge regarding the need to prime insulin pens before every injection, with some staff believing priming was only necessary for new pens. The DON, Administrator, and Corporate Nurse Consultant all confirmed that insulin pens should be primed before each use to ensure accurate dosing, but this was not consistently practiced by staff.