Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.67% based on 30 medication opportunities with two errors. One incident involved a Registered Nurse (LPN), Employee E4, who did not administer a 305-700mg dose of Potassium phosphate to a resident at the scheduled time of 8:00 a.m., instead administering it late during a medication pass at 9:40 a.m. Another incident involved LPN, Employee E1, who failed to administer an Adult 50 Plus multivitamin to a different resident because the medication was not in stock. Both incidents were confirmed by the respective LPNs and the Nursing Home Administrator acknowledged the facility's failure to maintain the required medication error rate.
Plan Of Correction
Residents #47 and #24 had no negative outcome. Education was provided to Licensed Nurse Employee #4 and #1. There were no other medication administration concerns identified during survey. To prevent this from recurring, the DON/designee educated licensed nursing on the 5 rights of medication administration and medication availability. To monitor and maintain ongoing compliance, the DON/designee will complete medication administration observations with 3 licensed nurses weekly x 4, then monthly x 2 to ensure medication administration is completed appropriately. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.