Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 6.67%, which exceeds the acceptable threshold of 5%. In one instance, a registered nurse (RN) administered Insulin Degludec to a resident without priming the needle as required by the manufacturer's guidelines. The nurse incorrectly believed that priming was only necessary for the first dose from the pen, despite instructions specifying that the pen should be primed before each injection to ensure proper dosing. In another case, a different RN administered only one tablet of Bumex (bumetanide) to a resident instead of the prescribed two tablets. The nurse misinterpreted the dosage, believing the tablets were 2 mg each when they were actually 1 mg, as indicated on the medication administration record and the medication card. This resulted in the resident receiving less medication than ordered by the physician. Both incidents demonstrate a failure to follow physician orders and established medication administration policies.