Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in two medication errors out of 27 observed opportunities, yielding a 7.41% error rate. The first error involved a resident with chronic kidney disease, anxiety, depression, hypertension, and arthritis, who was prescribed a lidocaine 5% patch to be applied to both wrists for neuropathy. During medication administration, the nurse applied the patch to only one wrist, contrary to the physician's order. The nurse acknowledged not following the five rights of medication administration and recognized this as a medication error. The second error involved a resident with Parkinson's disease, hypotension, and chronic kidney disease, who was prescribed multiple medications, including Omega 3 1000 mg to be administered once daily. During a medication pass, the nurse administered all prescribed medications except for Omega 3. The omission was observed and later confirmed by the nurse, who admitted to failing to follow the five rights of medication administration. The nurse and the DON both recognized this as a medication error and acknowledged that the medication was not administered as ordered. Both incidents were observed and confirmed through interviews with the involved nurses and the Director of Nursing. The facility's policies on medication administration and medication errors require that medications be administered as prescribed and that the medication error rate remain at or below five percent. The observed errors directly contributed to the facility exceeding the acceptable medication error rate.