Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
Surveyors observed that the facility failed to administer medications according to physician orders and manufacturer instructions for two out of three residents reviewed. In the first instance, a registered nurse administered digoxin to a resident without checking the resident's heart rate, despite a clear order to hold the medication if the heart rate was under 60 beats per minute. The nurse confirmed during interview that the heart rate was not checked prior to administration, although it was later found to be above 60 beats per minute. In the second instance, a nurse allowed a resident to self-administer a Dulera inhaler without supervision. The resident did not shake the inhaler before use, did not wait between puffs, inhaled incorrectly, and failed to rinse their mouth after administration, all contrary to manufacturer instructions and facility policy. The nurse confirmed these findings during interview. These two medication errors were identified out of 33 observed administrations, resulting in a medication error rate of 6.1%.