Medication Administration Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered, resulting in a 12% medication error rate (3 errors out of 25 opportunities), exceeding the 5% threshold. Facility policy on Medication Administration requires adherence to the seven rights and compliance with manufacturer specifications and professional standards, including shaking medications when indicated and following specific inhaler instructions. For one resident with asthma, the physician’s order for Albuterol Sulfate inhalation aerosol specified 2 puffs four times daily, with directions to shake well before administration and to have the resident rinse and spit afterward. During observation, an LPN handed the resident the Albuterol inhaler without shaking it, allowed the resident to take 2 puffs, and then returned the inhaler to the cart without instructing the resident to rinse and spit, despite the inhaler label including these directions. For a second resident with diabetes mellitus, the physician’s order for Insulin Lispro included a detailed sliding scale directing that a blood glucose of 356 or higher required administration of 20 units and a call to the MD. An LPN obtained a blood glucose result of 389 for this resident and administered only 18 units of Lispro insulin in the abdomen, later confirming that 20 units should have been given. For a third resident with diabetes mellitus, the physician’s orders included a fixed dose of 6 units of Insulin Aspart three times daily and a separate sliding scale that required 8 units for a blood glucose of 301–350. An RN obtained a blood glucose result of 348 and administered 14 units of Aspart insulin into the resident’s left upper arm using a vial that was confirmed to be expired. These observed deviations from physician orders and professional standards formed the basis of the cited medication administration deficiencies.
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