The facility had a 12% medication error rate based on 25 opportunities and 3 errors. An LPN gave a resident only one Lasix tablet instead of the ordered three, broke Potassium Chloride ER tablets in half before administration, and gave another resident only one Tamsulosin capsule instead of the ordered two-capsule dose. Staff interviews confirmed the errors, and the DON reviewed the findings.
Surveyors observed that an LPN committed three medication administration errors during a single medication pass, resulting in a medication error rate above 5%. A resident with dementia and a psychotic disorder, who had orders for Depakote sprinkles DR, a senna-docusate combination tablet, and polyethylene glycol powder measured in a calibrated cup, instead received a crushed Depakote enteric-coated tablet, a senna-only tablet, and polyethylene glycol measured with a plastic spoon. These actions were inconsistent with the facility’s crushing-medications policy and its “do not crush” list, and the DON confirmed the errors.
Surveyors observed that an LPN committed three medication errors during 36 administration opportunities, resulting in a medication error rate above 5%. A resident with an order for crushed medications received Ingreeza prepared by softening the capsule in pudding instead of sprinkling the capsule contents as ordered. The same resident did not receive ordered Flonase nasal spray and olopatadine eye drops because the medications were not available. The ADON confirmed the improper Ingreeza administration as a significant medication error, and the NHA acknowledged that the facility exceeded the allowable medication error rate.
Medication was not administered accurately for a resident with schizophrenia, schizoaffective disorder, bipolar disorder, and other psychiatric diagnoses. The resident had acute worsening psychosis with agitation, paranoia, and refusal of care, and orders were entered for Haloperidol 0.25 mg and Ingrezza 60 mg. However, the orders remained pending confirmation, the e-MAR showed missed doses, and an LPN administered Ingrezza 40 mg instead of the ordered 60 mg.
Medication administration errors caused the facility to exceed the allowed error rate. An LPN crushed medications that were listed as not to be crushed, including metformin ER, propranolol HCL, and Myrbetriq ER, for one resident, and another LPN administered Breo Ellipta to a resident without offering water or instructing the resident to rinse and spit afterward as required by policy and the manufacturer’s directions.
Medication Error Rate Exceeded Allowed Threshold: Surveyors observed incorrect med administration for two residents, including an LPN giving aspirin in the wrong formulation and tamsulosin at the wrong time/order details for one resident, and an RN giving Vitamin B-12 by mouth instead of sublingual for another resident. The facility’s med error rate was calculated at 10.71%, above the 5% limit.
Surveyors found that the facility did not keep its medication error rate below 5%, identifying 4 errors in 26 observed medication administrations. Policy required nurses to verify correct medication, dose, and resident, yet one LPN gave a resident only 500 mcg of cyanocobalamin instead of the ordered 1000 mcg. Another RN gave a different resident 500 mcg of cyanocobalamin instead of 4000 mcg, substituted Senna Plus (senna with docusate) for ordered senna alone, and administered enteric-coated aspirin instead of the ordered chewable form. The DON acknowledged that medications should have been given in the ordered forms and dosages.
Surveyors identified that the facility failed to keep its medication error rate below 5%, with two errors out of 29 observed doses. In one case, an LPN administered sucralfate to a resident after the resident had already eaten, contrary to the order to give it before meals and at bedtime. In another case, an LPN administered antibiotic eye drops followed immediately by lubricating eye drops to a resident without waiting the required interval between ophthalmic medications as specified in facility policy. The NHA and DON acknowledged that medications are expected to be administered as ordered and per standard practice guidelines.
The facility did not maintain a medication error rate below 5%, with two errors observed out of 28 medication administration opportunities. One resident received only half the prescribed dose of Losartan for cardiac conditions, and another received a crushed Protonix delayed release tablet, contrary to administration instructions. The DON confirmed these errors.
Two medication administration errors occurred when an LPN failed to have two residents rinse their mouths after receiving Fluticasone-Salmeterol (Advair) inhalation, as required by physician orders and manufacturer instructions. This resulted in a medication error rate of 8%, exceeding the acceptable threshold.
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