Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility was found to have a medication error rate of 15.15%, exceeding the acceptable threshold of 5%, as five medication errors were observed out of 33 opportunities during medication administration for three residents. One incident involved a nurse administering insulin via a pre-filled pen to a resident without priming the pen, contrary to both manufacturer instructions and facility policy. The nurse admitted to not knowing how to prime the pen and had not done so before, resulting in the resident potentially receiving an incorrect insulin dose. Another incident involved a nurse failing to administer two scheduled medications, Flovent and Xarelto, to a resident because the medications were not available at the time of administration. The nurse documented the missed doses and notified the nurse practitioner, but the medications were not given as ordered at the scheduled time. The resident had physician orders for these medications to manage conditions including COPD and a history of stroke or blood clots. A third incident involved a nurse preparing and administering more medications than were prescribed to a resident. The nurse prepared and administered thirteen medications instead of the eleven that were ordered, including duplicating doses of cholecalciferol and docusate. The nurse acknowledged the error after reviewing the medication administration record and confirmed that the resident received two doses of these medications instead of the prescribed amounts. Facility policies required medications to be administered as prescribed and checked against physician orders, which was not followed in these cases.