Failure to Maintain Acceptable Medication Error Rate Due to Lack of Observation During Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent, as evidenced by a calculated error rate of 17.24% based on 5 errors out of 29 observed opportunities. This deficiency was identified through observation, interview, and record review involving two residents who were being administered medications by nursing staff. The facility's own policy and competency assessments require staff to observe residents taking their medications to ensure they are swallowed and not left at the bedside, but this protocol was not followed. For one resident with multiple complex diagnoses, including diabetes, end stage renal disease, and pancreatic cancer, the assigned RN provided the resident with metoclopramide and pantoprazole in a medicine cup and placed a cup of liquid sucralfate on the bedside table. The RN then left the room without observing whether the resident took the medications, despite the resident expressing discomfort and holding the medication cup in her hands. The resident's care plan indicated a need for limited assistance with self-care, and her cognitive assessment showed moderate impairment in daily decision making. In another instance, an LVN administered medications to a resident with a history of sepsis, cellulitis, and gout. The resident, who was cognitively intact but required assistance with personal hygiene, took some pills but removed the docusate and placed it on her bedside table, expressing uncertainty about taking it. The LVN also left a cup of mixed protein liquid at the bedside without confirming ingestion. It was not determined if the resident ever took the docusate or the protein supplement. The DON confirmed that staff are required to observe residents taking their medications and that no residents were authorized for self-administration.