Medication Error Rate Exceeds 5% Due to Improper Administration and Documentation
Penalty
Summary
Surveyors identified that the facility failed to maintain a medication error rate below 5%, with observations revealing a 68.18% error rate during medication administration to two residents. During medication passes, staff administered incorrect medications, failed to follow manufacturer instructions for insulin administration, and did not adhere to facility policy regarding hand hygiene and documentation. Specifically, one LPN used an insulin syringe to extract insulin from a pen, contrary to manufacturer warnings and facility policy, due to a lack of appropriate pen needles. The same staff member also administered a probiotic that was not the one ordered and failed to notify the physician about late or missed medications. Another LPN was observed administering multiple medications late, failing to perform hand hygiene or wear gloves when administering eye drops, and documenting that a resident received medication that was actually refused. Additionally, scheduled doses of inhaled medications and topical treatments were not administered as ordered, and documentation did not reflect accurate administration times or refusals. Interviews with staff confirmed that medication administration was delayed due to staffing issues and meetings, and that there had been an ongoing shortage of insulin pen needles, which had not been adequately addressed by facility leadership. Review of facility policies showed clear requirements for medication administration timing, hand hygiene, and proper use of insulin pens, none of which were consistently followed. The DON and other staff acknowledged the lack of pen needles and the resulting improper insulin administration practices, as well as gaps in communication with pharmacy and among staff. The pharmacy confirmed a recent shortage of pen needles, but the facility had not implemented alternative solutions or ensured compliance with safe medication administration practices.