Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by five medication errors out of 26 observed opportunities, resulting in a 19% error rate. During a medication administration observation, a registered nurse was seen preparing and administering medications for a resident with multiple diagnoses, including hypertension, COPD, traumatic brain injury, and obstructive hydrocephalus. The nurse obtained the resident's vital signs and appropriately held certain blood pressure medications due to low systolic blood pressure, as per physician orders. However, the nurse proceeded to crush and combine all other scheduled medications, including a liquid supplement, into a single cup, added water, and administered the mixture through the resident's gastric tube without flushing the tube between each medication. The nurse confirmed during an interview that medications were crushed, combined, and administered all at once, and that a water flush was not performed between each medication. The resident's orders specified that medications should be crushed but did not authorize combining them. Facility policy required that medications administered through an enteral tube be prepared and given separately, with a flush of at least 15 ml of water after each individual medication. The observed practice was not in accordance with these orders or facility policy, resulting in multiple medication administration errors for the resident.