Medication Error Rate Exceeds Regulatory Limit Due to Dosing and Monitoring Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by federal regulations, resulting in a 12% error rate during a medication administration observation. Specifically, three medication errors were identified out of 25 opportunities involving two residents. One error involved a nurse preparing and nearly administering the wrong dose of acetaminophen to a resident with severe cognitive impairment and a physician's order for a specific dose. The nurse placed two 500 mg tablets in the medication cup instead of the ordered two 325 mg tablets, and acknowledged the error upon review. Another error occurred when a nurse administered Metoprolol and Amlodipine to a resident without first checking the resident's heart rate, as required by the physician's order. The order specified that both medications should be held if the systolic blood pressure was less than 110 or the heart rate was less than 60. The nurse admitted to not checking the heart rate prior to administration, which could have resulted in the medications being given outside of the prescribed parameters. Both residents involved had documented medical histories and cognitive assessments. One resident had dementia and schizophrenia with severely impaired cognitive abilities, while the other had hypertension and heart failure with intact cognition. The facility's policy required staff to verify the correct medication, dose, and administration parameters, but these procedures were not followed during the observed medication passes.
Plan Of Correction
F759: Free of Medication Error Rates 5 Percent or More CORRECTIVE ACTION On 3/7/25, LVN 4 was provided 1:1 in-service regarding checking of heart rate and blood pressure prior to administration of metoprolol and amlodipine. DON/Designee conducted in-service following 5 rights of medication administration, which are the standard of safe practice. OTHERS AFFECTED RESIDENTS IDENTIFICATION On 3/25/2025, the DON randomly followed nurses during med pass to check if residents were given metoprolol or amlodipine after heart rate was checked. No other residents were affected by the deficient practice. On 3/25/25, the DON conducted an in-service for 5 rights in medication of safe practices: > right patient > right dose > right route > right time > right drug And to follow up on the parameter for medications metoprolol and amlodipine and monitor heart rate and blood pressure. MEASURING AND SYSTEMIC CHANGES DON/Designee will perform random skill checks on licensed staff weekly to ensure that blood pressure and heart rate are checked prior to administering medications. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.