Medication Administration Errors and Noncompliance With Physician Orders
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5 percent, with surveyors identifying an 8.33 percent error rate during observation. For one resident with moderate cognitive impairment and no care plan focus or interventions for independent medication administration, an RN prepared multiple morning medications, including a nebulized Ipratropium-Albuterol treatment and oral medications such as Milvexian, Levothyroxine, acetaminophen, aspirin, Cymbalta, Levetiracetam, Meloxicam, Pantoprazole, Senna, and Cholecalciferol. The RN poured the nebulizer solution into the canister but did not start the nebulizer, then left the room and documented the treatment as completed in the electronic medical record. Subsequent observations showed the resident briefly turned the nebulizer on and then off, did not resume the treatment, and went to breakfast, leaving the medication still in the nebulizer canister. The DON confirmed the resident did not have an order for self-administration and that staff should not leave medications at the bedside or document administration before ensuring completion. Another resident with moderate cognitive impairment was observed receiving multiple medications, including Omeprazole, aspirin, Dulera inhaler, Fluticasone, Duloxetine, Guaifenesin, PreserVision ARED 2+ Multi Vital, Torsemide, and Cholecalciferol. After administering the medications, nasal spray, and Dulera inhaler, the RN did not provide water or an empty cup for the resident to rinse her mouth, despite a physician’s order specifying that the resident should rinse her mouth after each use of the Dulera inhaler. The facility’s Medication Administration Protocol required that all medications be administered in accordance with physician orders, prohibited documenting medications prior to administration, prohibited leaving medications at the bedside, and required staff to assure medications were taken prior to leaving the resident. The observed practices with both residents were inconsistent with these requirements and contributed to the identified medication error rate above the acceptable threshold.
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