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 a calculated error rate of 7.69 percent. During medication administration observations, three LPNs and two Certified Medication Aides (CMAs) were monitored across three halls, with a total of 25 medication opportunities reviewed. Two medication errors were directly observed involving one CMA administering medications to a resident. Specifically, the CMA administered only half the prescribed dose of Polyethylene Glycol 3350 and only one tablet of Senna Plus, despite physician orders for a full capful of Polyethylene Glycol 3350 and two tablets of Senna Plus every 12 hours. The errors were confirmed by the CMA during a subsequent interview. The resident involved had physician orders for these medications to address constipation.