Medication Error Rate Exceeds Acceptable Threshold Due to Improper Crushing
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5% during a medication administration pass on unit 3 south. Out of five observed medication administration opportunities, two errors were identified, resulting in a 40% error rate. Specifically, an LPN was observed crushing two medications that were clearly labeled by the manufacturer as 'Do not crush' on their blister packets. The LPN explained that all medications for the resident in question were being crushed and administered in applesauce due to the resident's swallowing difficulties and requirement for a thickened liquid diet. The facility's policy required medications to be administered as ordered and in accordance with manufacturer specifications, which was not followed in these instances.