Crushing of ER Medication and Omission of Ordered Laxative Result in Elevated Med Error Rate
Penalty
Summary
The deficiency involves failure to follow physician orders and facility policy during medication administration, resulting in a medication error rate above 5 percent. During a medication pass observation, a nurse (V4) administered Metoprolol Succinate ER 50 mg to a resident (R100) by crushing the extended-release tablet before giving it. Facility Medication Crushing Guidelines revised January 2018 state that time-release tablets, which are designed to release medication over 8 to 24 hours, should not be crushed. The facility’s Medication Administration Policy dated June 1, 2023, requires that medications be administered in accordance with written prescriber orders and established procedures. In the same observation and subsequent medication reconciliation, surveyors identified that R100 had a physician’s order for Polyethylene Glycol 3350 (Miralax) 17 grams powder for oral solution on the Medication Administration Record (MAR), but this medication was not administered by V4 during the morning medication pass. When interviewed later that morning, V4 stated that the medications observed being given were the only morning medications the resident had, despite the active Miralax order. Overall, there were 28 medication opportunities with 2 errors, resulting in a 7.14% medication error rate, exceeding the 5 percent threshold.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.