Medication Error Rate Exceeds Regulatory Threshold Due to Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation, resulting in a 16.13% error rate based on 31 observed opportunities with five errors. During medication administration, a Certified Medication Technician (CMT) did not administer several prescribed medications, including escitalopram oxalate, celecoxib, aspirin, and Eliquis, to a resident with multiple diagnoses such as atrial fibrillation, major depressive disorder, heart failure, and neuropathy. Despite this, the Medication Administration Record (MAR) was documented as if the medications had been given. The CMT was unsure whether the medications were administered and stated that double-checking the MAR was part of their routine, but could not confirm the administration during the observed period. In another instance, a Licensed Practical Nurse (LPN) administered Novolog insulin using a FlexPen to a resident with diabetes and cognitive communication deficit but failed to prime the pen before injection. The resident's blood sugar was checked, and the insulin dose was dialed and administered, but the required priming step was omitted. Interviews revealed inconsistent knowledge among nursing staff regarding the need to prime insulin pens before each use, with some staff unaware of the correct procedure as outlined by the manufacturer and facility expectations. Facility leadership, including the Assistant Director of Nursing, Nurse Manager, and Administrator, confirmed that staff are expected to follow physician orders, utilize the five rights of medication administration, and adhere to proper procedures such as priming insulin pens. The observed failures to administer medications as ordered and to follow correct insulin administration protocols directly contributed to the elevated medication error rate identified during the survey.