Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
Surveyors observed that staff failed to follow physician orders and facility policy during medication administration for two residents. In one instance, a nurse administered Allopurinol, Hydralazine, and Torsemide to a resident by crushing all medications together and mixing them with pudding, despite facility policy requiring each medication to be crushed separately and administered individually with food. This action was not in accordance with the facility's Medication Administration Policy and Procedure, which emphasizes safe and prescribed medication administration practices. In another case, a nurse administered Fluticasone Propionate nasal spray by giving two sprays in each nostril, contrary to the physician's order for one spray per nostril once daily. Additionally, the nurse administered two different inhalers (Symbicort and Spiriva) with insufficient intervals between doses and between different inhalers, not adhering to the facility's policy that requires at least one minute between doses of the same inhaler and at least two minutes between different inhalers. These deviations resulted in a medication error rate of 23.07% during the observed medication pass.