Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 12.5%. During medication administration observations, two licensed nurses were found to have made multiple errors. One nurse did not follow the physician's order for administering potassium chloride to a resident with a gastrostomy tube, crushing the tablet and dissolving it in only 10 ml of water instead of the prescribed 60 ml. The same nurse also failed to fully administer a crushed multivitamin with minerals, leaving an excessive amount of residue in the medication cup after administration. Another nurse administered only half the prescribed dose of lactulose to a resident, giving 10 gm instead of the ordered 20 gm. Additionally, this nurse administered a higher dose of vitamin D than prescribed, giving 1000 IU instead of 400 IU. These errors were confirmed through observation, interviews, and medical record reviews, and were not in accordance with the facility's policy and procedure for medication administration.