Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 8 errors observed out of 31 opportunities, resulting in a 25.8% error rate. Multiple instances were documented where staff did not administer medications as ordered, did not follow manufacturer instructions, or inaccurately documented medication administration. For example, a resident with diabetes and COPD did not receive prescribed doses of Dapagliflozin and Senna, and was not instructed to rinse and spit after using Advair Diskus, contrary to manufacturer guidelines. The Certified Medication Technician (CMT) involved did not provide the omitted medications and later inaccurately documented their administration. Another resident with heart failure, kidney failure, and hyponatremia did not receive prescribed doses of Potassium Chloride, Thiamine, and Aspirin, as the CMT failed to obtain these medications from stock or packaging but still documented them as given. Interviews with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) confirmed that staff are expected to administer all medications as ordered and not to document administration if medications were not provided. Additionally, insulin administration errors were observed for two residents with diabetes. In both cases, LPNs failed to prime insulin pens before administration, as required by manufacturer instructions for Tresiba and Novolog Flexpens. Interviews with nursing staff confirmed that insulin pens should be primed prior to dosing. These failures to follow proper medication administration protocols and documentation requirements contributed to the high medication error rate identified during the survey.