Medication Administration Errors Resulting in Exceeded Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with professional standards of practice, resulting in a medication error rate of 5.12%, which exceeded the required rate of less than 5%. During a medication pass observation, there were two errors out of 39 opportunities. For one resident with chronic kidney disease, reduced mobility, and lumbar intervertebral disc displacement, the care plan identified risk for gastrointestinal complications due to constipation with an intervention to administer medications as ordered. The physician had ordered MiraLAX 17 g by mouth once daily for constipation, but during observation the assigned LPN reported that the MiraLAX was not available and stated the resident would receive it the following day, indicating the ordered medication was not administered as prescribed. Another resident, admitted with type II diabetes mellitus and care planned for diabetes management with an intervention to administer medications as ordered, had a physician’s order for insulin lispro 6 units SQ before meals, to be held if blood sugar was less than 150. The resident had severe cognitive impairment but did not reject care and was largely independent with several ADLs. During observed medication administration, an LPN checked the resident’s blood sugar, found it to be 238, attached a needle to the insulin lispro pen, dialed the pen to 6 units, and administered the insulin SQ without priming the pen. In a subsequent interview, the LPN confirmed she did not prime the pen and stated that pens are never primed. Review of the insulin pen manufacturer’s instructions showed that a safety test (priming) of 2 units must be performed before each injection to ensure the pen and needle are working properly and to ensure the correct dose, demonstrating that the insulin was not administered in accordance with professional standards and manufacturer guidance.
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