Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by observations and interviews with staff. On December 3, 2024, a Registered Nurse, Employee E7, administered the incorrect form of Aspirin to two residents during medication administration. Resident R77 was given an Aspirin 81 mg chewable tablet instead of the prescribed Aspirin Enteric-Coated (EC) Tablet Delayed Release 81 mg, as per the physician's order dated September 28, 2020. Similarly, Resident R4 received the same incorrect form of Aspirin, contrary to the physician's order dated August 18, 2023, which specified the Enteric-Coated form for CVA treatment. The Registered Nurse confirmed these errors during interviews conducted at the time of observation. Consequently, the facility's medication error rate was calculated to be 5.7%.
Plan Of Correction
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. - Facility is unable to retroactively correct this deficient practice. - All residents residing in the facility are at risk of being affected. - Education for nursing staff will be completed to ensure that nurses administer the correct medications during medication passes. - DON/Designee will complete random medication pass competencies to ensure facility is free of medication errors. Audits will be done weekly by 4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed.