Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to adhere to medication administration policies and procedures, resulting in a medication error rate of 12%, which exceeds the acceptable threshold of 5%. Specifically, staff did not ensure that prescribed medications were available, dispensed the incorrect medication, and administered medication without proper authorization. In one instance, a registered nurse administered Hydrocodone to a resident who reported a pain level of 4, despite the medication being prescribed only for severe pain rated 7-10. The nurse acknowledged awareness of the order requirements but proceeded to give the medication regardless. In another case, a resident was prescribed Benzonatate and Guaifenesin-DM for cough and congestion. During medication administration, the nurse was unable to locate the prescribed Benzonatate and instead dispensed Guaifenesin, which was not the correct medication. The nurse confirmed the unavailability of the medication and did not follow the facility's policy to search for the medication or contact the pharmacy as required. These actions directly contributed to the identified medication errors.