Medication Administration Errors Resulting in Elevated Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 27 observed opportunities, resulting in an 18.52% error rate. Facility policies required medications to be administered as prescribed, using the five rights of medication administration and employing the MAR during administration, as well as following specific procedures for eye drop administration. The manufacturer’s instructions for dorzolamide-timolol ophthalmic solution also required pressing on the inner canthus for about two minutes after instillation to limit systemic absorption. For one resident, the MAR showed orders for dorzolamide-timolol eye drops three times daily, Symbicort inhaler twice daily, and Yupelri inhalation solution once daily. During observation, a CMT who was new to the facility and being oriented by another CMT administered the resident’s oral medications and eye drops. The resident tilted their head back and the CMT applied the drops, after which the resident immediately began blinking and was given a tissue to wipe their eyes. The CMT did not press on or hold the inner canthus after instilling the eye drops, and neither CMT administered the ordered Symbicort inhaler or the Yupelri breathing treatment at that time. For another resident, the MAR showed an order for magnesium oxide 400 mg once daily and polyethylene glycol 34 g once daily. During observation, a CMT removed a 500 mg magnesium oxide tablet from a bottle on the cart, crushed all of the resident’s medications, and mixed them with pudding, and mixed the polyethylene glycol with water. A second CMT administered the crushed medications and the polyethylene glycol mixture; after one sip, the resident stated the water was too cold. The CMT then took the polyethylene glycol mixture to the bathroom, returned with warm water in the resident’s bedside cup, and later discarded the original polyethylene glycol mixture in the trash on the medication cart. Staff interviews confirmed expectations to follow the five rights, administer medications in their entirety, and that CMTs may give inhalers and breathing treatments, but also revealed uncertainty among staff, including an LPN and CMT, about which eye drops require inner canthus pressure and for how long, despite the DON’s expectation that staff know this information.
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