Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12% error rate for three sampled residents. In one instance, a licensed nurse administered Dilaudid 6 mg to a resident with chronic pain without first counting the resident's respirations, as required by the physician's order. The nurse acknowledged not following the order, which specified withholding the medication if the resident's respiratory rate was less than 12. Another incident involved a nurse administering medication via gastrostomy tube (GT) to a resident with dysphagia without checking the tube's placement or flushing it with water prior to administration, both of which were required by the physician's order. The nurse admitted to not performing these steps, stating she forgot her stethoscope and did not verify the tube's position or perform the pre-flush for safety. A third deficiency occurred when a nurse handled and administered Finasteride, a hazardous drug, to a resident with a cancer diagnosis without wearing gloves, contrary to the medication's instructions and facility policy. The nurse acknowledged not following the required safety precautions, which were clearly indicated on the medication packaging and in the physician's order. Facility policies reviewed confirmed the necessity of adhering to prescriber orders and infection control procedures during medication administration.