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.
A medication error rate of 5 percent or greater was found during the survey, showing that the facility did not maintain medication administration errors below the required limit.
The facility failed to ensure the medication error rate remained below 5%, with errors identified in the administration of medications to two residents. An LPN did not properly measure a powdered laxative for a resident with gastrointestinal issues, and another resident with hypokalemia and hypothyroidism received multiple medications together and without food, contrary to orders and manufacturer instructions. Staff interviews confirmed that medications were not administered according to policy and best practices.
A medication error rate above 5% was identified when an LPN administered Atorvastatin and Loratadine to a resident in the morning instead of at bedtime as ordered. The LPN acknowledged the error, and the pharmacist noted potential impacts on medication efficacy and resident well-being. Both the DON and Administrator confirmed that medications are expected to be given as prescribed.
The facility failed to maintain a medication error rate below 5%, with two errors out of 34 opportunities, resulting in a 5.88% error rate. A resident with type 2 diabetes was affected when RN 7 administered Lantus insulin without performing a safety test and Humalog insulin without priming the pen, contrary to manufacturer's instructions. Interviews revealed a lack of adherence to guidelines, with staff not following proper procedures for insulin administration.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate. One resident with COPD was not prompted to rinse his mouth after receiving an inhaled steroid, and another resident with diabetes did not have the insulin pen needle left in place for the required time. Both errors were acknowledged by the staff involved, and the DON and Administrator confirmed the expectation for adherence to medication administration guidelines.
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.41%. Two residents were affected: one with atrial fibrillation did not receive Eliquis, and another with type 2 diabetes did not receive metformin, as both medications were unavailable. The KMA confirmed the absence of the medications, and the DON expected nurses to contact the pharmacy promptly.
A medication error rate of 5.71% was identified when a QMA administered eye drops to a resident in both eyes instead of the left eye as per physician's orders. The QMA followed medication labels rather than verifying the orders in the resident's chart, leading to the error. Interviews with staff indicated a failure to adhere to the facility's medication administration policy.
The facility had a medication error rate of 13.04%, with errors including incorrect insulin preparation and incomplete administration of crushed medications. Two residents were affected, one with diabetes and another with multiple medication orders.
An LPN on her first day at the facility administered eight medications prescribed for one resident to another, resulting in a medication error rate of 26.67%. The error occurred due to difficulties in logging into the computer and unfamiliarity with the residents, leading to incorrect resident identification.
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