Medication Error Rate Exceeds Acceptable Threshold Due to Policy and Procedure Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as 10 medication errors were observed out of 28 opportunities, resulting in a 35.7% error rate. Facility policy required medications to be administered according to prescriber orders, with staff verifying the right resident, medication, dosage, time, and method, as well as checking expiration dates. However, staff did not consistently follow these procedures. For example, a nurse documented a pain medication as refused when the resident only refused the applesauce it was mixed with, and did not offer an alternative food vehicle, despite knowing the resident's preference and the lack of pudding on the medication cart. Additionally, the same nurse failed to crush medications for another resident as ordered and did not check expiration dates prior to administration. Another nurse did not follow physician orders when administering vitamin C to a resident, giving four 250 mg tablets instead of two 500 mg tablets, and failed to check the medication against the MAR three times as required by facility policy. The nurse acknowledged the error and stated that the provider should have been contacted for a new order if the correct dosage form was unavailable. A registered nurse administering a corticosteroid inhaler did not follow the manufacturer's instructions, failing to instruct the resident on proper inhalation technique, breath holding, and mouth rinsing procedures. The nurse was unable to explain the differences between steroid and non-steroid inhalers or the importance of spitting out water after rinsing. The facility's Director of Nursing confirmed that staff are expected to follow both facility policy and manufacturer guidelines for medication administration.