Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 6.25%, which exceeds the acceptable threshold of 5%. During medication administration observations, two errors were identified out of 32 opportunities involving two residents. In one instance, a licensed nurse administered 4 units of Insulin Lispro subcutaneously to a resident after the resident had already eaten breakfast, despite the order specifying that the insulin should be given before meals. The nurse confirmed the insulin was given late and acknowledged that the medication should have been administered prior to the meal as ordered. In another case, a licensed nurse administered only one drop of Visine Dry Eye Relief in each eye to a resident, contrary to the physician's order for two drops in each eye twice daily. The nurse admitted to the error, stating unfamiliarity with such an order. The Director of Nursing confirmed that her expectation was for staff to follow the rights of medication administration and to give medications as prescribed, including correct timing and dosage. Facility policy also requires medications to be administered in accordance with prescriber orders and within specified time frames.