Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, with three errors identified in 25 observed opportunities, resulting in a 12% error rate. During medication administration, staff did not follow manufacturer instructions for insulin pen use for two residents with type 2 diabetes mellitus. Specifically, the LPN administered insulin injections and immediately removed the needle from the skin without holding it in place for the recommended 10 seconds, as specified by the manufacturer. The facility's own policy also did not align with manufacturer instructions, indicating a five-second hold, but this was not followed either. The DNS confirmed that staff did not adhere to the expected safety steps for insulin administration. Additionally, a resident prescribed Creon for digestive support did not receive the medication with food, as required by both manufacturer instructions and physician orders. The CMA administered Creon without offering a snack or meal, and no food was present in the resident's room at the time. The CMA stated that coordinating medication administration with meal times was challenging, and referenced the facility's policy allowing a one-hour window before and after scheduled medication times. The DNS acknowledged that staff were expected to follow physician orders regarding medication administration with meals.