Multiple Medication Administration Errors During Morning Medication Pass
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less when a medication aide (MA) was observed administering multiple morning medications to one resident outside the ordered administration time window of 0630 to 1100. During the observation period, all of the resident’s scheduled morning medications appeared in red on the electronic medication administration record (eMAR), indicating they were late. The MA acknowledged that administering medications late constituted a medication error, and the resident and an LPN both confirmed that all of the resident’s morning medications were given late. During the same medication pass, the MA did not follow facility policy or professional standards regarding the rights of medication administration and documentation. The MA removed medications from bubble packs, placed them into a medication cup, and documented them as given in the eMAR by clicking the “Y” button before the resident actually consumed them. The MA and the DON both confirmed that medications should not be signed out as administered until after the resident has taken them, and that this practice did not comply with the five rights of medication administration. The MA also administered an incorrect dose of a nasal spray and improperly handled a powdered laxative medication. For the nasal spray Azelastine 0.1%, which was ordered as one spray in each nostril, the MA administered two sprays in each nostril; both the MA and the resident confirmed the ordered dose and the error, and the DON confirmed this was a medication error. In addition, when preparing Polyethylene Glycol 3350, the MA poured the white granular powder into a 30 ml cup, realized grams could not be measured with that cup, and then discarded the medication-filled cup into a trash can instead of using the facility’s medication destroyer as required. The DON confirmed that this disposal method was not in accordance with facility policy.
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