Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication administration errors observed during 29 opportunities, resulting in a 6.90 percent error rate. Facility policy and manufacturer guidelines specify that certain medications, such as Oxycontin extended-release tablets, must not be crushed, and that oral inhalers like Dulera require the resident to rinse and spit out water after use. During medication administration, a registered nurse crushed an extended-release Oxycontin tablet before giving it to a resident, contrary to both the medication label and manufacturer instructions. The resident involved was cognitively impaired, dependent on staff for care, experiencing pain, and had multiple diagnoses including hip and humerus fractures, asthma, and respiratory failure. The same nurse also administered Dulera inhaler to the resident and provided a drink of water afterward, rather than instructing the resident to rinse and spit as required by the manufacturer. Both the nurse and the Director of Nursing confirmed these errors during interviews.