Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility was found to have a medication error rate of 6.9%, exceeding the acceptable threshold of 5%. This was determined through observation, interview, and record review during a medication pass task involving seven residents. Two errors were identified among 29 opportunities, affecting two residents. The errors involved the failure to administer medications at the ordered times, which is a violation of the facility's medication administration policy. The first error involved a resident with a history of hemiplegia and hypertensive heart disease, who did not receive her prescribed senna at the scheduled time. The Licensed Practical Nurse (LPN) responsible for administering the medication mistakenly believed she had given it and signed it off as administered. Upon being informed of the oversight, the LPN acknowledged the error and suggested administering the medication at a later time, which deviated from the prescribed schedule. The second error involved another resident with hypertensive heart and kidney disease, who received aspirin at the wrong time. The aspirin was ordered to be given at bedtime, but the LPN administered it earlier in the day. The LPN admitted to noticing the error but proceeded with the administration regardless. The Director of Nursing confirmed that both instances were medication errors, as the medications were not administered at the ordered times.