Medication Error Rate Above 5% Due to Improper Eye Drop Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 medication errors in 31 opportunities, resulting in a 6.45% error rate. For one resident (R7), a surveyor observed an LPN retrieve Prednisolone Acetate Ophthalmic Solution 1% from a medication cart; the eye drop bag had a blue sticker instructing to “shake well.” The LPN entered the resident’s room, checked the resident’s blood sugar, performed hand hygiene, donned gloves, and then administered one drop of Prednisolone Acetate 1% into the resident’s left eye without shaking the bottle. The surveyor did not observe any shaking of the eye drop bottle prior to administration. When questioned later, the LPN stated she had shaken the drops by tipping the bottle down and back up, and the nurse manager demonstrated that “shake well” should involve moving the hand back and forth quickly multiple times, confirming that the observed technique did not meet the expected standard. In a separate incident involving another resident (R9), a surveyor observed a CMA prepare multiple medications, including Cromolyn Sodium Ophthalmic Solution 4%. After verifying the oral medications, the CMA donned gloves and a gown, entered the resident’s room, and administered the oral medications with water. The CMA then informed the resident about the eye drops, handed the resident a tissue, and instilled two drops of Cromolyn Sodium 4% into the left eye while counting “one, two,” followed immediately by two drops into the right eye in the same manner, without waiting any time between drops in either eye. Later, when the DON was asked about proper eye drop administration, the DON stated that staff should wait one minute between drops of the same eye medication and three to five minutes between different eye medications. The surveyor’s observation that no waiting period occurred between drops for this resident constituted a second medication error.
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