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 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.
Medication Administration Errors Exceeded Facility Threshold: An LPN failed to administer some ordered medications because they were unavailable and did not notify the physician of the missed doses. During the same medication pass, the LPN gave Isosorbide Mononitrate ER incorrectly, administered Clonidine outside the ordered BP parameters, and gave the wrong total dose of Allopurinol. In a separate observation, Pantoprazole delayed-release tablets were crushed for a resident with GERD. The facility policy required medications to be administered safely and as prescribed, and the DON stated the expected medication error rate was below 5%.
Medication administration errors exceeded the allowed rate when surveyors identified 2 errors in 31 observed opportunities. An LPN gave a 6:00 AM Protonix dose that had already been documented as administered and did not give ordered calcium carbonate 600 mg because only a 500 mg strength was available; the MAR also lacked documentation that the medication issue had been addressed. The DON stated nurses are expected to give medications as ordered and contact the provider if the correct dose is not available.
Medication Error Rate Exceeded Threshold During Insulin Pen Administration: Surveyors found an eight percent medication error rate after observing two insulin administration errors involving two residents with DM receiving Humalog KwikPen insulin by sliding scale. An RN and a CMA each administered insulin without priming the pen after attaching the needle, and both confirmed the omission during interview. The DON and CCC stated staff training included priming the insulin pen to ensure proper function and accurate dosing.
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