Medication Administration Errors Result in Exceeded Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 28 medication administration opportunities, resulting in a 7.14% error rate. For one resident with diabetes mellitus, a physician order dated 12/06/25 directed administration of 20 units of Tresiba insulin via prefilled pen injector once daily subcutaneously. Manufacturer instructions for the Tresiba pen specified that the pen must be primed with 2 units before each dose by dialing to 2 units, holding the pen with the needle up, tapping gently, and pressing the button until the counter returned to 0 and a drop of insulin appeared. During an observation on 01/22/26, Nurse #5 removed the Tresiba pen from the medication cart, dialed the dose directly to 20 units, and administered the insulin without priming the pen as required by the manufacturer’s instructions. In a subsequent interview, the nurse stated she followed the five rights of medication administration and acknowledged she knew the pen should have been primed and believed she had primed it before giving the dose. In a separate incident, another resident had a physician order dated 01/13/26 for fluticasone furoate nasal spray, one spray in both nostrils once daily for sinus/allergies. On 01/22/26, during observed medication administration, Nurse #7 prepared and administered the nasal spray and was seen giving two sprays in each nostril instead of the ordered one spray in each nostril. In a later interview, the nurse recounted administering two sprays in each nostril, then reviewed the order, which specified one spray in each nostril, and stated she should have read the order more carefully. These two observed deviations from physician orders and manufacturer instructions during medication administration contributed to the facility’s medication error rate exceeding the 5% threshold.
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