Medication Error Rate Exceeds 5% Due to Omitted Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required by policy, resulting in an observed error rate of 6.67 percent during the survey. Out of 30 medication administration opportunities, two errors were identified involving two residents. In the first instance, an LPN was unable to administer a scheduled dose of Vitamin D3 1000 units to a resident because the medication was not available in either the resident's medication supply or the back-up supply. The LPN confirmed the omission of the dose. In the second instance, another LPN was preparing to administer Lantus insulin to a resident as ordered, but the multidose vial of insulin did not have an open date labeled, and there was no way to determine when it had been opened. Due to the lack of an open date and the absence of a back-up or emergency supply, the medication was not administered. The LPN confirmed this as an omitted dose. The administrator stated that her expectation was for medications to be available for each resident and that medications should be reordered before the supply is exhausted.