Medication Administration and Documentation Errors Resulting in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 6 errors out of 31 medication administration opportunities, resulting in a 19.35% error rate. For one resident, record review showed active orders for Calmoseptine ointment to be applied to the bilateral buttocks four times daily for barrier protection and a daily multivitamin tablet related to a sacral pressure ulcer. During a medication pass observation, the medication aide documented both the Calmoseptine and the multivitamin as “given,” but did not remove either medication from the cart or administer them at that time. In an interview during the observation, the medication aide confirmed charting the Calmoseptine as given but stated it would not actually be administered until the resident left the dining room. For another resident, record review showed active orders for Flonase nasal spray for nasal congestion and drainage, Ipratropium Bromide nasal solution for sinusitis, Nystatin powder ordered both as needed and scheduled for application under the breasts for itching, and Potassium Chloride oral tablets as a nutritional supplement. The facility’s documentation policy required accurate charting, proper correction of errors, and detailed documentation of treatment refusals, including resident response, reasons for refusal, and physician notification. Observation of a medication pass revealed the medication aide charted all of these medications as “given,” but only removed oral tablets from the cart and mixed them into pudding. When the resident refused the Potassium Chloride tablet, the aide removed the pill from the pudding and discarded it in the resident’s trash without attempting to discuss the need for the medication or notifying nursing or providers of the refusal. The resident later confirmed that the Nystatin powder, Flonase nasal spray, and Ipratropium Bromide nasal solution were not offered and described using the nasal spray only after blowing the nose and the Nystatin powder after showering or when excessively sweating.
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