Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required. During a medication pass observation, a Licensed Practical Nurse (LPN) prepared and administered 17 medications to one resident, including Folic Acid. However, the resident was ordered to receive 1 mg of Folic Acid but was instead given only 400 mcg. For a second resident, the LPN prepared and administered nine medications, but failed to administer Atorvastatin 20 mg as ordered. Additionally, several of this resident's medications, scheduled for 8:00 am, were not administered until 9:21 am. A total of 28 ordered medications were reviewed during the observation, with two errors identified, resulting in a medication error rate of 7%. The facility's policy requires verification of the five rights of medication administration at three separate points and mandates the use of the medication administration record (MAR) during medication passes. Despite these policies, the observed errors occurred, and the facility's reported census at the time was 76 residents.