Significant Medication Administration Errors Identified
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by multiple incidents involving improper medication administration. In one instance, a registered nurse administered insulin to a resident with diabetes mellitus type II without priming the insulin pen, contrary to manufacturer instructions and the user guide, which state that priming is necessary to remove air and ensure accurate dosing. The nurse confirmed during an interview that she did not prime the pen and was unaware of the requirement. Additionally, two other residents experienced missed doses of critical medications. One resident did not receive two scheduled doses of the antibiotic Keflex, despite the medication being available in the facility's emergency medication box. Another resident missed several scheduled doses of the anticoagulant Xarelto, and the medication was not administered with meals as ordered. The Director of Nursing confirmed the missed doses and the timing issue with meal administration. These failures were identified through observation, medical record review, staff interviews, and policy review.