Medication administration errors were observed for 3 of 32 opportunities, resulting in a 9.37% error rate. An LPN gave a multivitamin, aspirin chewable, and memantine 5 mg that did not match the physician orders on the MAR for two residents. The LPN confirmed the discrepancies, and the DON stated medications should match the orders and that the MAR had linked the wrong memantine strength to the pharmacy supply.
Medication administration errors resulted in an 8% error rate during observation. An LPN gave a resident Caltrate 600+D3 with the wrong vitamin D dose compared with the MAR, and the facility policy required verification of the right drug, dose, time, method, and patient, with scanning of the med and armband as a safety check. Two residents had cognitive impairment, including one with severe impairment and one with moderate impairment, and the incorrect dosage was confirmed by the LPN during the med pass.
Medication administration errors resulted in a 10% error rate during observation. An LPN gave a resident Calcium 600 + D instead of the ordered calcium carbonate, withheld ordered antihypertensives without physician hold parameters based on nursing judgment, and administered Tresiba without properly priming the insulin pen or holding it in place long enough, with leakage noted at the injection site.
Medication administration errors were observed involving an RN and two residents. One resident with DMII received Lantus without the insulin pen being primed and had leakage at the injection site, while Metformin ER doses were missed when the medication was unavailable and later a formulation mismatch occurred between the order and the MAR. Another resident received Biotin 5,000 mcg instead of 1 mg, and Psyllium was repeatedly unavailable and not administered as ordered.
Medication administration errors exceeded the allowed rate when an LPN documented topical creams as given even though they were not administered, and an RN crushed enteric coated aspirin for another resident despite the medication not being appropriate to crush. Facility policy required accurate MAR documentation and that do not crush medications not be crushed.
Medication administration errors exceeded the allowed rate when surveyors found five errors in 31 opportunities. An LPN gave a medication even though the expiration date could not be read, administered amlodipine despite the resident’s BP being below the hold parameter, another LPN failed to give ordered gabapentin and guaifenesin because they were not available, and an LPN held scheduled insulin based on nursing judgment even though no hold order existed. The DON confirmed medications were expected to be available, not expired, and not held without a physician order.
Medication Error Rate Exceeded 5 Percent: Surveyors found 3 medication errors in 38 opportunities, resulting in a 7.89% error rate. An LPN gave a resident citalopram 20 mg instead of the ordered 10 mg and administered hydralazine after it had already been given earlier that morning. In a separate observation, another LPN gave a resident Mucinex 400 mg instead of the ordered 600 mg ER dose.
Medication Error Rate Exceeded 5 Percent: The facility had a 12.5% medication error rate, with four errors in thirty-two opportunities. An RN administered scheduled G-tube meds when one aspirin could not be crushed and the correct alternative was not available, resulting in a late dose after a new order was obtained. In another event, an LPN found multiple meds unavailable for a resident, including Bumex, metoprolol, and citalopram; some were later pulled from the Pyxis after the scheduled time, and metoprolol was not given on one day. Staff interviews and record review showed repeated missing medications during med pass.
A medication error rate exceeded the allowed threshold after surveyors found four errors in 26 opportunities for one resident with COPD. An RN gave the inhaled steroid before the bronchodilator, did not have the resident rinse his mouth after the steroid, and did not complete the ordered PICC saline flushes as prescribed. The RN said she was unaware of the required inhaler sequence and wait time and routinely gave only part of the ordered flush; the RN/Unit Manager and DON confirmed the expected medication administration practices.
A medication administration review found a 12% error rate, with four errors in 33 opportunities. A CMA administering insulin to a resident withdrew the pen immediately after injection, causing leakage, and an LPN present did not identify the error. In another pass, a CMA removed and replaced a lidocaine patch but had documentation showing it was removed earlier when it was not, and potassium chloride was documented as given even though it was not administered. The DON acknowledged the observed practices were not consistent with facility expectations.
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