Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by 3 errors out of 43 observed opportunities, resulting in a 6.98% error rate. Facility policy required staff to review the five rights of medication administration multiple times during the process, including verifying the correct medication, dose, and administration instructions. However, during medication administration observations, staff did not consistently follow these procedures. For one resident with a history of heart failure and atherosclerotic heart disease, a registered nurse administered only one tablet each of aspirin and sennosides-docusate sodium, instead of the two tablets ordered for each medication. In another instance, a resident with a history of joint replacement and osteoarthritis was ordered to receive Bengay cream applied to both knees and hands four times daily, but the nurse applied the cream only to the knees, omitting the hands. Interviews with nursing staff and facility leadership confirmed that staff were expected to follow physician orders and the seven rights of medication administration, but these expectations were not met during the observed medication passes.