Medication Administration Errors Resulting in 14% Error Rate
Penalty
Summary
Surveyors identified a medication error rate of 14% (4 errors out of 29 opportunities), exceeding the 5% threshold, related to medication administration practices for two residents. For one resident, an RN prepared oral medications and subcutaneous insulin and brought them to the resident’s room. When the resident asked if her diuretic was in the cup and requested that it be removed so she could take it later, the RN stated that it was present, left the room, and then searched through the medication cup at the cart, touching three pills with bare hands while attempting to identify the diuretic. The RN then returned and administered all medications, including the diuretic, without informing the resident that the diuretic remained in the cup. During the same medication pass, the RN was unable to locate the resident’s ordered nasal spray, stated she would obtain a new one from backup supply, and did not administer the nasal spray. Medication reconciliation later showed the diuretic was documented as “held” even though it was given, and the nasal spray was omitted and not given, and the medication cart lacked the nasal spray. During preparation and administration of the resident’s insulin lispro, the RN did not follow manufacturer instructions: she failed to clean the pen’s rubber seal with alcohol, primed the pen while holding it horizontally instead of with the needle pointing up, and held the injection site for only two seconds, after which a drop of blood appeared at the site. The DON confirmed these steps were inconsistent with expectations and standards of practice. For a second resident, another RN prepared medications and initially dispensed an enteric-coated aspirin 81 mg instead of the ordered chewable aspirin 81 mg, placing it in the medication cup with other medications. When questioned, the RN reviewed the order and acknowledged the aspirin form was incorrect and needed to be replaced with the chewable form. These observed errors and omissions occurred despite a facility policy requiring medications to be administered as ordered, in accordance with professional standards, and with proper verification and documentation on the MAR.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.