Medication Error Rate Exceeds Acceptable Threshold Due to Improper Water Flushes
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with three medication errors identified out of 25 observed medication administration opportunities, resulting in a 12.5% error rate. Specifically, a Licensed Vocational Nurse (LVN) did not administer the prescribed amount of water flush (10-15 cc) between each medication given via gastrostomy tube (GTube) to a resident, instead using only 5 cc of water between medications. This was observed during medication administration at the resident's bedside, and the LVN acknowledged the error, stating that the correct amount of water should have been used as per the physician's order. The resident involved had significant medical needs, including gastrostomy status, moderate protein-calorie malnutrition, aphasia, and severely impaired cognitive skills, and was dependent on tube feeding for nutrition and hydration. The resident's care plan and medication administration record both specified the need for 10-15 cc water flushes between medications. The facility's policy also required medications to be administered as prescribed. The Director of Nursing confirmed that water flushes should be given as ordered to ensure proper medication administration.