Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 10.34% during the survey. This deficiency was identified through observations, record reviews, and interviews involving two residents. Specifically, during a medication administration observation, a Licensed Practical Nurse (LPN) administered several medications to a resident but failed to provide the 81 mg Delayed Release medication as ordered. Similarly, a Registered Nurse (RN) administered medications to another resident but also omitted the 81 mg Delayed Release medication as per the physician's order. The Director of Nursing (DON) was informed of these medication administration concerns by the Unit Manager, who verified the omissions. The facility's policy on medication administration emphasizes adherence to the 10 rights of medication administration, including ensuring the right drug is administered as per the physician's order. However, the staff failed to comply with this policy, leading to the identified medication errors.
Plan Of Correction
Residents #102 and #361 were evaluated for any negative consequences with none noted. The physicians and resident representatives were notified with no new orders received. Facility residents that receive medications have the potential to be affected. The Director of Nursing/Staff Development Coordinator will complete medication administration competencies on each licensed nurse to validate staff competency related to medication administration with focus on preventing medication errors. The Director of Nursing/Staff Development Coordinator will educate licensed nurses on the policy and procedure for medication administration including following physician orders and preventing medical errors. The Director of Nursing/Staff Development Coordinator will complete 5 random weekly medication administration observations to ensure medications are provided as ordered. Observations will be completed on each shift and weekends. Results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.