Medication Administration Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, as required. During medication administration observations, two errors were identified out of 25 opportunities, resulting in an 8% error rate. Specifically, a Licensed Practical Nurse (LPN) administered Fluticasone-Salmeterol (Advair) Inhalation Aerosol Powder to two residents without ensuring they rinsed their mouths after use, as directed by both the physician's orders and the manufacturer's instructions. The omission of this step was observed during the morning medication pass. Both residents had physician orders specifying the use of Fluticasone-Salmeterol for asthma and COPD, with explicit instructions to rinse the mouth after each administration to reduce the risk of side effects such as oral thrush. The LPN confirmed during an interview that she did not have the residents rinse their mouths after administering the medication. The Director of Nursing also confirmed that the mouth rinsing step should have been completed for both residents following administration of the inhaled medication.