Medication Error Rate Exceeds Acceptable Threshold Due to Incomplete Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with two medication errors identified out of 25 observed opportunities, resulting in an eight percent error rate. During medication administration for a resident with severe cognitive impairment, dependent on a feeding tube, a Licensed Vocational Nurse (LVN) prepared and administered medications using the same G-tube syringe for all crushed medications. The LVN did not fully administer Acetazolamide and Oyster Shell Calcium/Vitamin D as prescribed, leaving significant residue in the medication cup. The LVN acknowledged that only 30% of the Oyster Shell Calcium and 50% of the Acetazolamide were administered, with the remainder left in the cup and not given to the resident. The Director of Nursing confirmed that the medications were not administered in accordance with the physician's orders. Facility policy requires medications to be administered as prescribed, but this was not followed in this instance.