Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 8%, which exceeds the acceptable threshold. During medication administration observation, a registered nurse did not follow the instructions on the medication label for an ophthalmic suspension prescribed for a resident with multiple diagnoses, including bilateral secondary cataract and heart disease. Specifically, the nurse failed to shake the eye drops bottle before administering the medication, as required by the label instructions. In another instance, the same nurse incorrectly programmed an IV medication pump for a resident with cellulitis, quadriplegia, and a history of venous thrombosis. The nurse entered an incorrect infusion volume into the pump, differing from the prescribed amount on the medication label. Both incidents were confirmed through observation, interview, and record review, and were not in accordance with the facility's policy and procedure for administering medications.