Failure to Maintain Acceptable Medication Error Rate During Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent when surveyors observed three medication errors out of 32 opportunities, resulting in a nine percent error rate. In one instance, an LPN administered Metoprolol ER 25 mg, ordered by mouth with explicit "do not crush" instructions, by crushing the tablet, mixing it with water, and giving it through a PEG tube to a resident. This action was contrary to the medication order and the facility’s medication administration policy, which specifies that medications are to be administered in accordance with professional standards of practice and that medications with "do not crush" instructions are not to be crushed. In another instance, an LPN administered Miralax 17 g to a resident but measured only approximately half the ordered dose by filling the granules in the cap up to the inside threading rather than to the stamped 17 g line. When questioned, the LPN stated they had been told by another nurse to measure to the threading and believed filling the entire white portion of the cap was "too much" based on a prior experience with another resident. Later, the unit manager demonstrated that the correct 17 g dose corresponded to filling the entire white portion of the cap up to the purple part, and acknowledged that the amount previously administered by the LPN was not the full ordered dose. The DON also acknowledged these observations as medication errors.
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