Medication Error Rate Exceeds Regulatory Limit Due to Improper Administration
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5%, as required by regulation. During observation of 35 medication administrations, three errors were identified, resulting in an error rate of 8.57%. The errors were associated with one resident who had physician orders for potassium, divalproex, and artificial tears. The medication administration record and medication packaging for potassium and divalproex clearly indicated 'Do Not Crush,' yet the medication aide crushed all of the resident's oral medications before administration. The aide stated that they had been instructed to always crush this resident's medications, despite the explicit instructions not to do so. Additionally, the medication aide administered eye drops incorrectly by pulling up the resident's upper eyelid and placing the drop directly onto the eye, rather than forming a pouch in the lower eyelid as required by facility policy. Both the medication aide and a registered nurse confirmed that crushing medications labeled 'Do Not Crush' and improper eye drop administration constituted medication errors. Facility policies reviewed specified adherence to the six rights of medication administration, compliance with manufacturer specifications, and correct technique for administering eye drops, all of which were not followed in these instances.