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 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 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 administration errors exceeded the allowed rate after an LPN gave multiple ordered G-tube medications by mouth to a resident and administered Seroquel at half the ordered dose. The resident’s orders and MAR matched, but the nurse did not follow the prescribed route or dosage, and facility leadership stated nurses were expected to follow physician orders and the rights of medication administration.
Surveyors identified a 24% medication error rate when an LPN crushed and mixed multiple medications together for administration through a GT for a resident, contrary to professional standards, and omitted a scheduled Coreg dose without contacting the pharmacy or checking emergency stock. Review of MARs showed multiple missing documentation entries for three residents, including anticoagulants, analgesics, inhalation treatments, GI medications, topical antifungals, enteral feedings, and related blood pressure checks. The DON acknowledged that mixing crushed medications for GT administration was a deficient practice and confirmed the missing MAR documentation, while the Administrator stated that medications must be administered per policy and professional standards.
Surveyors identified multiple medication administration errors and policy noncompliance, including an LPN giving a multivitamin without minerals instead of an ordered vitamin-mineral tablet, failure to apply a prescribed Lidoderm patch when it was unavailable and inaccurate MAR documentation indicating it was given, administration of Metoprolol despite the resident’s SBP being below the ordered hold parameter, and an RN administering long-acting insulin outside the ordered morning time without priming the insulin pen or holding it in place after injection. Staff interviews revealed lack of adherence to MAR verification requirements and unfamiliarity with proper insulin pen technique.
The facility experienced a medication error rate of 17.24%, significantly above the acceptable threshold, due to multiple instances of omitted doses, late administration, and failure to follow proper medication administration procedures. Errors included missed doses of prescribed medications, lack of instruction for inhaler use, and delays caused by medication unavailability, as confirmed by staff interviews and pharmacy records.
Two residents were not instructed to rinse and spit after receiving corticosteroid inhalers, resulting in a medication error rate above 5%. LPNs failed to follow facility policy and manufacturer instructions, despite clear labeling on the medication packaging. Interviews confirmed staff awareness of the requirement, but the step was omitted during observed medication passes.
Staff failed to ensure the medication error rate remained below five percent, with three errors observed among 35 opportunities. Errors included administering an incorrect dose of an inhaler to a resident with heart and lung conditions, preparing an expired allergy medication for a resident with multiple chronic illnesses, and incorrectly administering a disintegrating antipsychotic tablet. Nursing staff confirmed these were medication errors.
Surveyors identified that two medication errors occurred when a nurse administered an incorrect dose of Omega-3 and failed to measure and apply Voltaren gel as ordered for a resident. The nurse did not use a measuring tool for the topical medication and omitted application to one area, resulting in a medication error rate above the acceptable threshold.
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