Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
A medication aide (MA) failed to follow proper medication administration procedures for a resident, resulting in a medication error rate of 12%, which exceeds the acceptable threshold of 5%. During observed medication administration, the MA did not instruct the resident to rinse their mouth after using the Trelegy Ellipta inhaler, as required by both manufacturer instructions and facility competency guidelines. Additionally, the MA did not use the provided dosing card to measure the correct amount of Diclofenac Sodium gel before applying it to the resident's ankles, instead using a finger to scoop the medication from a cup. These actions were confirmed by the MA during an interview. Further, the MA administered an as-needed (PRN) dose of acetaminophen to the resident for a reported headache without first obtaining permission from the nurse, as required by facility protocol. The MA only informed the nurse of the administration after the fact. The nurse confirmed that the MA should have sought approval prior to giving the PRN medication. These failures in medication administration practices were observed and documented during the survey, affecting one of five sampled residents.