State Findings:
Based on observations, interviews and record review the facility failed to ensure residents were kept free from significant medication errors for two (#6 and #8) of four reviewed out of 33 sample residents.
Specifically, the facility failed to ensure:
-An insulin pen was primed before administered to Resident #6, to ensure the correct insulin dose was given; and,
-Resident #8 did not receive expired medication.
Cross-reference F759 failure to ensure the facility was free of medication error rates of five percent or greater.
III. Failure to ensure Resident #6’s insulin [MEDICATION(S)] was primed prior to administration
Licensed practical nurse (LPN) #1 was observed preparing and administering medications to Resident #6 on [DATE] at 7:50 a.m. LPN #1 prepared [MEDICATION(S)] (insulin) [MEDICATION(S)] 16 units for Resident #6. She dialed the [MEDICATION(S)] to 16 units and administered it to the resident in her right arm. She did not prime the [MEDICATION(S)] prior to administration.
LPN #1 was interviewed immediately afterwards. She said the [MEDICATION(S)] needed to be primed routinely and she primed the insulin pen sometimes. She acknowledged the [MEDICATION(S)] needed to be primed with 2 units prior to administration to ensure the resident received their accurate dose of medication.
Failure to ensure Resident #8 received unexpired medication
Registered nurse (RN) #1 was observed preparing and administering medications to Resident #8 on [DATE] at 7:35 a.m. RN #1 prepared [MEDICATION(S)] 600 mg 1.5 tablets administered them to Resident #8. The [MEDICATION(S)] 600 mg half tablet was individually packaged with an expiration date of [DATE].
RN #1 was interviewed immediately following the administration. She said the packaging on the medication card looked as though the date of expiration was [DATE] and acknowledged it had been crossed out with the new expiration date of [DATE]. She said she needed to take the information to the director of nursing for review and contact the pharmacy for follow-up.
The DON and regional nurse consultant (RNC) were interviewed on [DATE] at 1:48 p.m. The DON said the nurses were educated on how to prime insulin pens prior to administration. She said LPN #1 knew how to prime the insulin pen, but she was nervous.
The DON was interviewed a second time on [DATE] at 11:31 a.m. She said she notified the pharmacy regarding the error and change in expiration date of the Resident #8’s [MEDICATION(S)]. She said she was told the medication ([MEDICATION(S)] 600 mg half tablet) had a 28 day expiration date. She acknowledged the medication error. She planned to provide training regarding the decreased end date of the [MEDICATION(S)] when split.
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