Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by observations and record reviews involving three residents during medication administration. One LPN administered eye drops to a resident but did not complete the medication administration before attending to another resident's vital signs. The nurse also failed to ensure the resident was administering the eye drops correctly as ordered by the physician, and there was no documentation of an order or assessment for self-administration of the medication. Additionally, another LPN administered a fish oil capsule to a resident by cutting it open and mixing the contents with applesauce, contrary to the physician's order and drug instructions, which specified the capsule should be swallowed whole. Observation revealed that some medication remained in the capsule shell after administration. For another resident, the LPN removed and applied lidocaine patches to the resident's knees instead of the lower back as ordered, and did not follow the prescribed wearing schedule. The nurse, who was from an agency and unfamiliar with facility protocols, could not provide further details regarding the administration. These actions resulted in a medication error rate of 14.81%, significantly exceeding the acceptable threshold.