Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, as required. During medication administration observations, two errors were identified out of 35 opportunities, resulting in an error rate of 5.71 percent. One error involved a nurse crushing Metoprolol Extended Release (ER) tablets for a resident, despite manufacturer instructions and physician orders specifying that the ER tablets should not be crushed, as this could alter the medication's effectiveness and safety. The nurse confirmed the error during an interview, as did the Quality Assurance and Performance Improvement Registered Nurse. A second error was observed when a nurse administered Voltaren 1 percent gel to a resident without measuring the prescribed two-gram dose as directed by the manufacturer and physician orders. Instead, the nurse applied the gel by squeezing it onto her gloved hand and then onto the resident's toes, without using the dosing card to ensure the correct amount. The nurse acknowledged during an interview that she routinely applied the gel in this manner and did not measure the dose. The Quality Assurance and Performance Improvement Registered Nurse also confirmed that the gel should have been measured according to the manufacturer's instructions.