Medication Error Rate Exceeds 5% Due to Improper Administration Techniques
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less during a medication pass, resulting in a cumulative error rate of 10.3% based on three medication errors out of 29 opportunities. Two residents were directly affected by these errors during observed medication administration by licensed nursing staff. The errors were identified through observation, interview, and record review. For one resident with a gastrostomy tube and diagnoses including diabetes mellitus, muscle weakness, and hyperthyroidism, the nurse did not flush the G-tube with the prescribed amount of water after administering methimazole. The resident's physician orders and facility policy required flushing the tube before and after medication administration to ensure the full dose was delivered. The nurse acknowledged forgetting to flush the tube, and the DON confirmed that failure to flush could result in the resident not receiving the correct medication dose. Another resident with glaucoma and diabetes mellitus received ophthalmic medications, Brimonidine and Brinzolamide, without the nurse applying pressure to the inner eye after administration. Physician orders and manufacturer instructions specified that pressure should be applied to the inner eye to ensure proper medication delivery and absorption. The nurse admitted to forgetting this step, and the DON confirmed its importance in medication administration for ophthalmic treatments.