Medication Error Rate Exceeds Acceptable Threshold Due to Incomplete Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 7.41 percent during a medication pass observation. Specifically, two medication errors were identified out of 27 opportunities, involving the incomplete administration of glycopyrrolate and ascorbic acid (Vitamin C) to a resident. The errors occurred when the nurse did not ensure the medications were fully dissolved and administered, leaving a white pasty residue in the medication cups after administration via the resident's G-tube. The resident involved had significant medical needs, including respiratory failure, a tracheostomy, and a G-tube for feeding, and was assessed as having severely impaired cognitive skills and high dependence on staff for daily activities. Physician orders required the administration of glycopyrrolate and Vitamin C via the feeding tube, but the nurse failed to properly mix and dissolve the medications before administration, resulting in the resident not receiving the full prescribed doses. Both the nurse and the Director of Nursing confirmed during interviews that the medications were not fully administered as required, and that facility policy mandates medications be properly mixed and fully delivered with no visible residue left in the cups. The failure to follow these procedures led to the resident not receiving the complete doses of their prescribed medications.