Medication Error Rate Exceeds Regulatory Threshold Due to Administration Errors
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5%, as required by regulation, with observations revealing a rate of 10.71% based on 3 errors out of 28 medication administrations. The errors involved three residents. For one resident, a Certified Medication Assistant (CMA) administered an Advair Diskus inhaler but did not instruct the resident to rinse their mouth after use as ordered, instead providing water to drink. The CMA confirmed during interview that the resident was not cued to rinse their mouth. For two other residents, a Licensed Practical Nurse (LPN) administered insulin using insulin pens but primed the pens with only 1 unit instead of the 2 units specified in the manufacturers' instructions. The LPN confirmed during interviews that the pens were primed with 1 unit for both residents. Manufacturer instructions for both Lispro and Lantus insulin pens require priming with 2 units to ensure proper dosing. These actions resulted in medication administration errors as observed and documented by surveyors.