§483.45(f) Medication Errors.
The facility must ensure that its-
§483.45(f)(1) Medication error rates are not 5 percent or greater;
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Observations:
Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to maintain a medication error rate less than five percent on one of three nursing units. (West Unit)
Findings include:
A review of the facility policy entitled, "Medication Administration," last reviewed January 30, 2024, revealed that staff were to administer medications as ordered by the physician. Medications were to be administered 60 minutes prior to or after the scheduled times unless otherwise specified by the physician.
Clinical record review revealed that Resident 1 had diagnoses that included stroke, hypertension (HTN), and arthritic pain. A review of physician's orders dated January 5, 2024, and February 8, 2024, revealed that staff were to administer the following medications at 8:00 a.m. daily: tramadol (a pain medication) 50 mg, and metoprolol (a blood pressure medication) 25 mg. Observation of the medication pass on March 1, 2024, revealed that licensed practical nurse (LPN) 1 administered Resident 1's medications at 9:40 a.m.
Clinical record review revealed that Resident 2 had diagnoses that included gastroesophageal reflux disease (GERD), anxiety, seizures, and diabetes. A review of physician's orders dated January 8, 2023, March 14, 2023, June 16, 2023, December 11, 2023, and January 10, 2024, revealed that staff were to administer the following medications at 8:00 a.m. daily: lamotrigine (an anticonvulsant medication) 150 mg, levetiracetam (an anticonvulsant medication) 500 mg, Ativan (an antianxiety medication) 0.5 mg, Novolog (insulin) based on sliding scale parameters, Novolog 70/30 14 units, and omeprazole (a stomach acid reducing medication) 20 mg. Observation of the medication pass on March 1, 2024, revealed that LPN 1 administered Resident 2's medications at 10:00 a.m. The Novolog based on sliding scale parameters was administered at 10:18 a.m.
Clinical record review revealed that Resident 4 had diagnoses that included HTN, GERD, urinary retention, and depression. A review of physician's orders dated October 14, 2022, revealed that staff were to administer the following medications at 8:00 a.m. daily: amlodipine (a medication for high blood pressure) 5 mg, and lisinopril (a medication for high blood pressure) 10 mg. A review of physician's orders dated October 14, 2022, July 28, 2023, and January 19, 2024, revealed that staff were to administer the following medications at 9:00 a.m. daily: ferrous sulfate (iron) 325 mg, finasteride (a medication for enlarged prostate) 5 mg, Prozac (an antidepressant medication) 20 mg, and famotidine (a stomach acid reducing medication) 20 mg. Observation of the medication pass on March 1, 2024, revealed that LPN 1 administered Resident 4's medications at 10:36 a.m.
In an interview on March 1, 2024, at 9:35 a.m., LPN 1 confirmed that the medication pass was late.
Observation during the medication pass on March 1, 2024, from 9:40 a.m. through 10:36 a.m., revealed 24 medication opportunities with 15 medication errors which resulted in a medication error rate of 62.5%.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 03/26/2024
1.Resident 1, 2 and 4 received their medications, there were no ill effects.
LPN 1 no longer an employee at facility
2. All residents have the potential to be affected by the deficient practice
3. Licensed professional nursing staff were educated on policy and procedures for Medication Administration Medication Administration times were reviewed with physicians to ensure optimal and timely delivery of medications to residents.
4. Unit managers/designee will conduct review of EMAR's daily x 3 days then weekly x 3, then monthly x 2 or until compliance is sustained. Any issues identified will be addressed with the physician. Results of findings will be reviewed at QAPI committee monthly.
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