Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 6.45%, which exceeds the acceptable threshold. Specifically, one resident with type two diabetes, morbid obesity, and chronic obstructive pulmonary disease was observed receiving six units of Humalog insulin via a KwikPen without the required two-unit air shot being dialed up prior to administration. The nurse administering the medication confirmed that this step was omitted, which is contrary to the manufacturer's instructions for use of the Humalog KwikPen. Additionally, another resident with diagnoses including anxiety disorder, schizophrenia, and depression was administered an incorrect dose of Vitamin E. The nurse provided a Vitamin E capsule of 180 mg (400 IU) instead of the prescribed 100 units. The nurse confirmed the error during an interview. In total, two medication errors were observed out of 31 medications administered, and the facility's policy requires medications to be administered safely, timely, and as prescribed.