Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from medication error rates of 5% or greater, as evidenced by three medication errors out of 28 observed opportunities, resulting in a 10.71% error rate. In one instance, a resident with an order for Keppra oral tablets to treat epilepsy was instead prepared to receive an unmeasured dose of liquid Keppra by an LPN, who acknowledged both the inaccurate measurement and the incorrect medication form. In another case, a resident with an order for GlycoLax powder to be mixed with 6 ounces of fluid was prepared to receive the medication mixed in only approximately 4 ounces of water, with the LPN failing to accurately measure the prescribed amount of fluid despite being questioned by the surveyor. Additionally, the same resident had an order for Fluticasone nasal spray, to be administered as one spray in each nostril twice daily. However, the LPN handed the medication to the resident without confirming self-administration authorization, and the resident self-administered two sprays in each nostril instead of one. There was no documentation of an order permitting self-administration, and the LPN acknowledged both the deviation from the prescribed dose and the lack of a self-administration order. The Director of Nursing Services confirmed that medications should be administered according to physician orders and that self-administration requires proper assessment and authorization.