Medication Error Rate Exceeds Acceptable Threshold Due to Improper Bubble Pack Opening
Penalty
Summary
The facility failed to ensure that the medication error rate during medication administration was below 5%. During a medication pass observed by the surveyor, an LPN was seen using a ballpoint pen to stab open bubble packs containing medications for two residents. This method was used for a total of 20 out of 32 medication administration opportunities, resulting in a medication error rate of 62.5%. The LPN laid out the bubble packs on the medication cart, exposed the pen tip, and punctured each pack to dispense the tablets into a medication cup before administering them to the residents. One resident received eight different medications, including Amlodipine, Certravite, Folic Acid, Hydrochlorothiazide, Turmeric, Vitamin B complex, Thiamine, and Vitamin C. Another resident received twelve medications, including Tamsulosin, Losartan, Memantine, Metoprolol ER, Thiamine, Vitamin K with D3, Aspirin, Chlorthalidone, CoQ10, Folic Acid, Gabapentin, and Glimepiride. The improper method of opening the bubble packs was observed by the surveyor, and one resident expressed concern about their medications being crushed, which the LPN denied. The Director of Nursing was notified of the surveyor's findings and acknowledged the concerns.