Medication Administration Errors and Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate medication administration in accordance with physician orders and facility policy, resulting in a 16% medication error rate during the survey’s 25 observed opportunities. One resident had an order for a Multiple Vitamins-Minerals tablet once daily for supplementation, but the LPN administered a One-Daily Multivitamin without minerals, which did not match the ordered medication. Facility policies required verification of the right medication, dose, time, and route against the MAR and checking labels multiple times, but these steps were not followed in this instance. Another resident had an order for a Lidoderm (Lidocaine) 5% patch to be applied to the lower back every 12 hours and removed per schedule, but the nurse did not administer the patch because it was not available on the cart, in the medication room, or in the automated medication system. The physician was not notified of the missed dose, and the MAR reflected that the patch had been administered on multiple occasions despite the lack of available patches. The unit manager was initially unaware of the unavailability, and the resident later reported not receiving the patch the previous day or on the day of interview, instead requesting Tylenol for pain. A third resident had an order for Metoprolol Tartrate 25 mg by mouth once daily for HTN, with instructions to hold the dose if HR was 50 or lower or if SBP was below 120. At the time of administration, the resident’s BP was 109/54 mmHg and HR was 56, yet the LPN administered the medication outside the ordered BP parameter, stating she only considered the HR and not the BP. A fourth resident had an order for Insulin Glargine (Lantus) 26 units subcutaneously every morning and at bedtime for diabetes, but the RN administered the morning dose at 1:11 PM instead of in the morning, did not prime the insulin pen, and did not hold the pen in place after injection as required by manufacturer guidance and facility expectations. The RN reported being unfamiliar with the procedures for priming and holding the insulin pen and had not received training on the facility’s insulin pen administration policy.
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