Medication Administration Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, as required, resulting in a calculated error rate of 6.9% (two errors out of 29 opportunities). Facility policy for eye drop administration required staff to wait at least five minutes before applying additional medication to the eye. During a medication pass observation, one LPN administered sucralfate 1000 mg to a resident after the resident had already completed breakfast, despite the medication packaging specifying that it was to be given before meals and at bedtime. The LPN acknowledged during an immediate interview that she was running behind and that the medication was not administered as ordered. In a separate observation, another LPN administered Cipro HC 0.3% ophthalmic solution, one drop to each eye, and then immediately administered Refresh lubricating eye drops, one drop to each eye, without waiting between the two medications as required by facility policy. During an immediate interview, this LPN confirmed that the eye drops were given consecutively without the required interval. During a subsequent interview, the Nursing Home Administrator and Director of Nursing confirmed that they expected nursing staff to administer medications as ordered and in accordance with standard practice guidelines. These observed deviations from ordered medication administration and facility policy resulted in the cited medication error rate above the 5% threshold.
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