Medication Error Rate Exceeds 5% Due to Incorrect Administration Routes and Failure to Follow Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 16.13% during a medication pass observation. Five medication errors were identified out of 31 opportunities, involving two residents. For one resident with a history of stroke, hypertension, depression, and respiratory failure, physician orders specified that multiple medications were to be administered via G-Tube. Despite accurate transcription of these orders in the electronic Medication Administration Record (eMAR), a nurse prepared and attempted to administer these medications orally, based on information received during the morning report that the resident no longer had a G-Tube. The nurse did not assess the resident prior to administration, and it was later confirmed by the resident and the unit manager that the G-Tube was still in place and medications should have been given via that route. In another instance, a resident with diabetes mellitus had an active physician order for Glucophage (metformin) to be administered with meals. During medication pass observation, the nurse prepared and administered the medication without providing food or a meal, as required by the order. The nurse later stated she was unaware of the specific instruction to give the medication with meals, as she had not read the entire medication order. This resulted in the medication being administered contrary to the physician's instructions. Both incidents were observed directly by surveyors and involved failures to follow physician orders as documented in the eMAR and on medication bottles. The errors were attributed to the nurse's reliance on verbal information from shift report without verifying the resident's current status or reviewing the full medication orders, as well as a lack of assessment prior to administration.