Medication error rate exceeded the 5% threshold when an RN administered two insulin doses to a resident with DM without priming the Lantus and NovoLog pens before each injection. Surveyors observed the RN give the ordered subcutaneous doses without completing the manufacturer-required safety test, and the RN stated she believed priming was only needed before first use. The DON and consultant pharmacist confirmed the pens should be primed before each dose.
Medication Error Rate Exceeded 5% Due to Improper Crushing of Extended-Release Medications: A resident with diabetes, vascular dementia, epilepsy, and depression received multiple medication administration errors when an LPN crushed extended-release carbidopa-levodopa and metoprolol succinate and opened duloxetine capsules for applesauce administration based on shift report and a printed note. The LPN later stated she should have recognized the extended-release medications should not have been crushed, and the DON stated the nurse should have checked the chart and MAR instead of relying on verbal report and the shift-change paper.
Medication Error Rate Exceeded Allowed Threshold: A resident with anemia, muscle weakness, and depression received medication pass errors when an MA omitted an ordered B Complex supplement and gave only one tablet of Sertraline 25 mg instead of the ordered three tablets plus a 100 mg tablet. The MA stated she missed the B Complex on the MAR and did not notice the full Sertraline dose; the DON stated the usual process was to compare the medication cards to the MAR before administration, and the PA stated medications should be given as ordered.
Medication Error Rate Exceeded 5 Percent: Surveyors found an 11.5% med error rate during an observation of five residents. An RN gave a resident with CHF only half of the ordered Torsemide dose and documented the full dose, and gave another resident Vitamin C without a current order plus only half of the ordered Vitamin D dose. The RN acknowledged the errors, and the consultant pharmacist stated staff must follow the MAR and physician orders before administering meds.
Medication Administration Errors Exceeded Allowed Rate: Surveyors found an 11.5% med error rate after observing a medication aide administer meds to a resident with heart failure. The aide did not follow the ordered timing for metolazone and bumetanide and did not instruct the resident on the correct dose of fluticasone nasal spray, resulting in multiple med administration errors.
Medication Error Rate Exceeded Threshold: The facility had 3 medication errors out of 39 opportunities, resulting in a 7.69% error rate. One nurse failed to administer ordered cholecalciferol and fenofibrate to a resident with vitamin D deficiency and hyperlipidemia because the stock dose did not match the order and one medication was unavailable. Another nurse administered a fluticasone propion-salmeterol inhaler to a resident with COPD but did not prompt the resident to rinse and spit as directed by the manufacturer.
Surveyors identified a medication error rate above 5% when a nurse, unable to locate a prescribed polysaccharide iron complex capsule for a resident with iron deficiency and other conditions, substituted and administered an acidophilus probiotic tablet that had no corresponding physician order. The nurse stated she believed the two could be interchanged because they were both probiotics. Subsequent interviews with nursing leadership and the NP confirmed that the two medications are different, should not be substituted by staff, and that the provider should have been notified when the ordered medication was unavailable, resulting in the resident not receiving the prescribed iron supplement.
Surveyors identified that the facility exceeded the acceptable medication error rate when a nurse withheld a prescribed dose of metoprolol for a resident with cardiac conditions despite vital signs not meeting the physician-ordered hold parameters, and did so without obtaining a concurrent physician order. In a separate instance, the same nurse allowed a resident with COPD to self-administer fluticasone nasal spray without instruction, resulting in the resident rapidly delivering three sprays into each nostril instead of the ordered two sprays per nostril, and the nurse did not correct the technique or dosage.
Surveyors identified that the facility failed to keep its medication error rate below 5%, finding three errors among 26 opportunities (11.45%). One resident with constipation did not receive a prescribed daily dose of polyethylene glycol when an RN mixed the laxative, placed it on the over-bed table, administered other meds, and left the room without giving it. Another resident with constipation received only part of a polyethylene glycol dose when an RN gave a single drink of the dissolved laxative, then left the remaining medicated solution at the bedside and exited the room. A third resident with GERD, ordered calcium carbonate 600 mg each morning, was administered 1000 mg when an RN used tablets labeled 1000 mg and later acknowledged not realizing a 600 mg strength existed.
Surveyors observed that a nurse administered an 81 mg enteric-coated aspirin instead of the ordered 81 mg chewable aspirin and failed to administer ordered polyethylene glycol 3350 to a cognitively intact resident, contributing to 2 errors out of 30 opportunities and a medication error rate above 5%. The nurse reported she did not notice the aspirin formulation difference and chose not to offer the polyethylene glycol because the resident usually refused it, while the resident stated he typically has regular bowel movements and would notify staff if that changed.
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