| 9115 |
AGAPE NURSING & REHAB CENTER |
425379 |
300 AGAPE DRIVE |
WEST COLUMBIA |
SC |
29169 |
2011-09-14 |
332 |
E |
0 |
1 |
YQ1X11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, review of the facility provided policy for "Eye Administration" and interview, the facility failed to ensure that it was free of medication error rate of five (5) percent or greater. The medication error rate was 10%. There were 4 errors out of 40 opportunities for error. The findings included: Error #1: On 9/13/2011 at 9:00am, during observation of the medication pass on the Comprehensive Care Unit (CCU), Registered Nurse (RN) #1, was observed to instill two (2) drops of [MEDICATION NAME] Ophthalmic eye drops into the left eye (OS) of Resident A back to back. The Drug Facts and Comparisons book (updated monthly), page 1725, states (under "General Considerations in Topical Ophthalmic Drug Therapy"): "If multiple drop therapy is indicated, the best interval between drops is five (5) minutes....This ensures that the first drop is not flushed away by the second or that the second is not diluted by the first". During review of the "Eye Administration" policy on 9/13/2011 at 11:50am, it states "Wait 10-15 minutes between administrations of different types of eye drops to same eye". During an interview on 9/13/11 at 2:40pm, RN #1 confirmed that she did not think that she had to wait between eye drops since it was the same medication. RN #1 stated, it was her mistake and she would find out what was the correct administration timing between each eye drop administration. Error #2: On 9/13/2011 at 9:00am, during observation of the medication pass on the Comprehensive Care Unit (CCU), RN #1 was observed to instill two drops of [MEDICATION NAME] Ophthalmic Suspension into both eyes (OU) of Resident A without shaking the bottle prior to administration. The Drug Facts and Comparisons book, page 1725, states (under "General Considerations in Topical Ophthalmic Drug Therapy"): "Resuspend suspensions (notably, many ocular steriods) by shaking to provide an accurate dosage of drug". During an interview on 9/13/2011 at 2:40pm, RN #1 revealed that she did not shake the [MEDICATION NAME] Ophthalmic Suspension prior to administering the eye drops. Error #3 and #4: On 9/13/2011 at 9:00am, during observation of the medication pass on the Comprehensive Care Unit (CCU), RN #1 was observed to instill two drops of [MEDICATION NAME] Ophthalmic Suspension into both eyes (OU) of Resident A with less than 3 minutes between each eye drops. In the left eye (OS) the first eye drop was administered at 9:09:19am, and second drop was administered at 9:11:18am with a time lapse of 1:59. In the right eye (OD) the first eye drop was administered at 9:09:46am, and the second drop was administered at 9:11:30am with a time lapse of 1:44. The Drug Facts and Comparisons book (updated monthly), page 1725, states (under "General Considerations in Topical Ophthalmic Drug Therapy"): "If multiple drop therapy is indicated, the best interval between drops is five (5) minutes....This ensures that the first drop is not flushed away by the second or that the second is not diluted by the first". During review of the "Eye Administration" policy on 9/13/2011 at 11:50am, it states "Wait 10-15 minutes between administrations of different types of eye drops to same eye". During an interview on 9/13/2011 at 2:40pm, RN #1 stated, it was her mistake and she would find out what was the correct administration timing between each eye drop administration. |
2015-08-01 |