Medication Error Rate Exceeds 5% Due to Incorrect Dosage and Supplement Administration
Penalty
Summary
The facility failed to ensure medication error rates remained below 5%, resulting in an observed error rate of 6.06% during medication administration. In one instance, an LPN administered only one 100 mg tablet of Amiodarone to a resident with an order for 200 mg daily, instead of the required two tablets. The LPN acknowledged the mistake, stating that the order required two tablets, and the DON confirmed that not giving the correct dosage constitutes a medication error. The resident's physician order was clear, and the DON described the expected process for medication administration, which includes verifying the correct dose and medication. In another instance, an LPN administered one tablet of Vitamin D 1000 units to a resident whose order specified Vitamin D3 5000 units plus an additional 1000 units of Vitamin D3, totaling 6000 units. The LPN admitted uncertainty about the difference between Vitamin D and Vitamin D3 and selected the incorrect supplement. The DON confirmed that Vitamin D and Vitamin D3 are not equivalent and that the nurse should have administered the correct form and dosage as ordered. Both incidents were observed and confirmed through interviews and record reviews, demonstrating a failure to follow physician orders and facility policy regarding medication administration.