Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during observed medication administration on two of four nursing units. Over the course of two observation periods, there were 26 medication administration opportunities, with four errors identified, resulting in a medication error rate of 15.38%. These errors were confirmed by the Director of Nursing. Specific deficiencies included a nurse not instructing a resident with chronic obstructive pulmonary disease and diabetes to rinse their mouth after using a tiotropium bromide inhaler, and failing to clean the tops of two insulin pens with alcohol before attaching needles, contrary to physician orders and manufacturer instructions. Additionally, another nurse crushed an extended-release acetaminophen tablet before administering it to a resident with chronic pain and dementia, despite drug information stating that these tablets should not be crushed.