Medication Error Rate Exceeds Regulatory Threshold Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by three medication errors observed out of 25 opportunities, resulting in a 12 percent error rate. In one instance, a resident with severe cognitive impairment and multiple diagnoses, including major depressive disorder and dementia, was administered 10 mg of Namenda instead of the physician-ordered 5 mg. The LPN responsible confirmed the error during an interview. In another case, a resident with similar cognitive and psychiatric conditions was given crushed Plavix and Wellbutrin Extended Release, as well as the contents of an Auvelity capsule, mixed into pudding. The LPN acknowledged crushing the medications, despite manufacturer instructions stating that Wellbutrin Extended Release tablets should be swallowed whole to prevent rapid drug release and increased side effects. A third medication error involved a resident with a recent femur fracture, MRSA, and diabetes, who required insulin administration for a high blood glucose reading. The RN administering Lispro insulin failed to prime the insulin pen before injection, as required by manufacturer guidelines, which could result in an incorrect dose being delivered. The RN confirmed the omission during a post-administration interview. These observed errors contributed to the facility's medication error rate exceeding the regulatory threshold.