Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
A medication error rate of 5.56% was identified during a medication pass, with two errors observed out of 36 opportunities involving two residents. For one resident with type 2 diabetes mellitus, a registered nurse administered glipizide 2.5 mg as ordered, but failed to ensure it was given 30 minutes prior to meals as specified in the physician's order. The medication was administered in the afternoon without confirmation of the timing in relation to meals. For another resident with a BIMS score indicating cognitive intactness and a diagnosis of low cortisol, a licensed vocational nurse administered hydrocortisone 5 mg without food, contrary to the physician's order to give the medication with food. The nurse assumed the resident had eaten a snack earlier, but the resident confirmed no food was consumed during the relevant time frame. The facility's policy requires medications to be administered according to physician orders, but this was not followed in these instances.