Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, resulting in a 12.49% error rate during observed medication administration. Surveyors observed medication passes for three residents, during which four errors occurred out of 28 opportunities. For one resident, a nurse failed to administer Risperidone and Oyster shell calcium as ordered, and did not provide the correct dose of Vitamin C, Acetaminophen, and Polyethylene glycol according to the frequency specified in the physician's orders. Another resident received only one tablet of Vitamin D3 instead of the ordered two tablets. A third resident was administered Fluticasone nasal spray with two sprays in each nostril, contrary to the physician's order for one spray in each nostril. These errors were identified through direct observation of medication administration, review of the Medication Administration Record (MAR) and Physician Order Sheet (POS), and interviews with nursing staff. The Director of Nursing confirmed that nurses are expected to follow the five rights of medication administration and acknowledged that missed or incorrectly administered medications could have effects on residents. The facility's medication administration policy requires checking all medications against the MAR and following specific instructions, which was not consistently done during the observed medication passes.