Failure to Perform Insulin Pen Safety Checks: An LPN failed to perform the required safety test/priming step before administering Lantus and Novolog to two residents with DM and hyperglycemia. Observation and interviews showed the LPN attached new needles and injected insulin without priming the pens, and the facility’s medication error rate was 9.38% (3 errors in 32 opportunities), above the 5% threshold.
Medication administration error rates were 11.11%, above the required threshold of less than 5%. During observation of 27 med passes, surveyors identified three errors. One resident with IBS, constipation, and severe cognitive impairment did not receive ordered polyethylene glycol, and the CRMA said it was withheld because of diarrhea but was not documented. Another resident with DM and constipation had an active Basaglar insulin order, and the report references the insulin priming instructions as part of the observed error review.
Surveyors found that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses from pens that were not primed according to manufacturer instructions. An LPN and an RN each attached a needle and dialed the ordered insulin dose on insulin pens for two different residents, then proceeded to administer the injections without first priming with 2 units as required. The DHS and interim ED stated that nurses were expected to follow manufacturer guidelines, and another LPN confirmed that pens should be primed before dialing the ordered dose, but there was no specific facility policy on insulin use, contributing to the observed errors.
Crushed ER and DR Medications Given to a Resident: An RN was observed crushing and administering Pantoprazole DR and Isosorbide ER to a resident even though both unit-dose labels said do not crush. The RN stated she noticed the ER designation on the Isosorbide only after the pass, and interviews with an LPN, the pharmacist, the DON, and the Administrator confirmed that ER and DR medications are not to be crushed.
Medication administration errors exceeded the allowed rate when a CMT made multiple errors during observed med passes for two residents. Errors included giving incomplete doses of polyethylene glycol, failing to have residents rinse and spit after inhaler use, applying ophthalmic gel to both eyes instead of one eye as ordered, and administering less lactulose than prescribed. The facility policy required meds to be given according to orders and the five rights checked three times.
Medication administration errors exceeded the allowed rate, with multiple observed failures involving insulin, eye drops, and oral medications. An RN did not prime an insulin pen before injection, another RN failed to give ordered artificial tears and gave eye drops in both eyes instead of one, a second RN omitted another ordered eye drop, and an RN gave Synthroid late and did not administer polyethylene glycol. Staff interviews showed inconsistent understanding of medication timing and administration requirements.
A medication error rate above 5% was identified when an LPN observed that a resident’s scheduled hydrocodone-acetaminophen dose had not been given and no reason had been documented at the time, and that the resident’s scheduled saccharomyces boulardii dose was unavailable in the cart and pyxis. The MAR later reflected the missed narcotic dose as not administered and the probiotic dose as unavailable, while the LPN stated the physician/medical director would be notified.
Medication error rate exceeded 5% during observed med pass. A QMA made multiple med errors for two residents, including giving incorrect doses of escitalopram and potassium chloride, omitting ordered Januvia, cyanocobalamin, polyethylene glycol, calcium with D3, and fluticasone, and stating some meds were missed because they were on order or overlooked on the MAR. The DON and ED stated meds were expected to be given per physician orders and the five rights of medication administration.
A facility exceeded the allowed medication error rate, with 4 errors in 32 opportunities. Errors included an LPN crushing an enteric-coated aspirin, an LPN giving insulin without priming the pen, an LPN preparing the wrong dose of diltiazem ER, and an RN initially preparing the wrong dose of buspirone. Staff interviews showed gaps in medication administration knowledge and inconsistent use of the MAR and medication labels.
Medication administration errors exceeded the allowed rate when an RN crushed two medications that should not have been crushed. One resident with a history of atherosclerotic heart disease received crushed potassium chloride ER, and another resident with hyperlipidemia received crushed fenofibrate. The DON acknowledged the medications were crushed when they should not have been, and the facility's error rate was 6.90%.
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