Medication Error Rate Exceeds 5% Due to Improper Handling
Penalty
Summary
A deficiency occurred when a nurse (LVN) failed to follow proper medication administration procedures for a resident with severe cognitive impairment and multiple health conditions, including malnutrition and immunodeficiency. During a medication pass, the LVN poured several oral tablets from bulk stock bottles into her bare hand, selected one tablet to administer, and returned the remaining tablets to the bottle. This process was observed with both cyanocobalamin (Vitamin B12) and ferrous sulfate (iron) tablets. The LVN acknowledged during the observation that this was not the correct procedure and that she should not have touched the medications with her bare hand or returned them to the bottle. The facility's medication administration policy, revised in January 2024, specifically instructed staff not to touch oral medications with bare hands. The Director of Nursing confirmed that the LVN's actions were not in line with facility policy and explained the correct method for separating tablets. The survey found that the medication error rate for the observed medication pass was 8%, exceeding the acceptable threshold of 5%. The incident was documented as a failure to ensure medication error rates remained below 5% for residents reviewed for pharmacy services.