Medication Administration Errors and Failure to Follow Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders and to maintain a medication error rate below 5%. Surveyors reviewed records for three residents and observed medication administration by an LPN. Resident #11, admitted with cerebral palsy, gastro-esophageal reflux disease without esophagitis, and major depressive disorder, had a physician order for 30 mL of Mylanta maximum strength oral suspension twice daily. During observed medication administration, the LPN instead gave 30 mL of Milk of Magnesia 1200 mg per 15 mL. In a subsequent interview, the LPN confirmed she did not administer the ordered Mylanta because she thought Milk of Magnesia was the same medication. Resident #47, admitted with multiple diagnoses including anemia, pancreatic cyst, gastritis, vitamin D deficiency, cerebral infarction without residual deficits, essential hypertension, metabolic encephalopathy, other specified pancreatic disease, and vascular dementia, had a physician order for 30 mL of lactulose oral solution 20 gm per 30 mL. The LPN administered potassium 20 mEq instead and confirmed in interview that the ordered lactulose was not given. Resident #112, admitted with hematuria, chronic diastolic congestive heart failure, obstructive sleep apnea, chronic obstructive pulmonary disease, cardiac murmur, anxiety disorder, essential hypertension, and a single subsegmental thrombotic pulmonary embolism without acute cor pulmonale, had orders for daily cyanocobalamin 1 mg and apixaban 5 mg twice daily. Observation showed the LPN administered vitamin D2 1.25 mg (50,000 IU) without an order and did not administer the ordered cyanocobalamin or apixaban. These actions were inconsistent with the facility’s Administering Medications policy, which requires medications to be administered safely, timely, and as prescribed.
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