Medication Error Rate Exceeds 5% Due to Incomplete Administration via G-Tube
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required, with 3 errors out of 37 opportunities, resulting in an 8 percent error rate. During a medication pass, LVN J did not administer the full dose of carvedilol, misoprostol, and famotidine as ordered by the physician to a resident with multiple complex medical conditions, including chronic atrial fibrillation, coronary artery disease, stroke, diabetes, and severe cognitive impairment. The resident was dependent on staff for all activities of daily living and received medications via gastrostomy tube. On the observed medication pass, LVN J prepared the medications by crushing them and placing them in a medication cup, but did not stir or rinse the cup, leaving a significant amount of residue. The nurse was about to discard the cup with the remaining medication when a surveyor intervened and pointed out the residual. LVN J acknowledged the error and subsequently administered the remaining medication after adding water. LVN J stated she had received gastrostomy tube training but was nervous during the process. The facility's policy required medications to be administered safely, timely, and as prescribed.