Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent, as evidenced by an observed error rate of 18.52 percent during the survey. Two residents were directly affected by medication administration errors. One resident was administered 15 milliliters of liquid Potassium Chloride via an enteral feeding tube, despite the physician's order specifying only 3.75 milliliters. Additionally, the enteral tube was not flushed with water prior to or immediately after medication administration, contrary to facility policy, with the post-administration flush occurring approximately one hour later. The resident was receiving tube feeding at the time, which was stopped for medication administration, but the required flushing steps were not followed. Another resident was given insulin (Humalog/Lispro) that was past its discard date, as indicated on the packaging. The insulin vial also lacked an open date, which is required by facility policy to ensure proper tracking and timely disposal. The LPN responsible for administering these medications did not adhere to established protocols for medication administration, including checking expiration dates and following procedures for enteral tube medication delivery. These actions were confirmed through direct observation, staff interviews, and review of physician orders and facility policies.