Medication Error Rate Exceeds Five Percent Due to Administration and Availability Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a 12% error rate with three errors observed in 25 opportunities. For one resident with diabetes, an LPN administered insulin using a FlexPen without priming it as directed by the manufacturer’s instructions, despite the resident’s care plan and physician order specifying insulin administration per sliding scale. The LPN confirmed not priming the pen, and the DON stated that priming is necessary before dialing the dose. Additionally, two residents missed scheduled doses of their prescribed medications due to unavailability. One resident with COPD and heart failure did not receive a scheduled dose of a bronchodilator inhaler because the medication was not available on the medication cart, and the LPN confirmed it needed to be reordered from the pharmacy. Another resident with Alzheimer’s disease and pain management needs missed a scheduled dose of topical capsaicin cream for pain relief, also due to the medication not being available and requiring reorder. These incidents were observed during medication administration and confirmed by staff interviews and record reviews.