Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications according to physician orders, resulting in a medication error rate of 7.69%, which exceeds the acceptable threshold. In one instance, a resident with severe cognitive impairment and a diagnosis of oropharyngeal cancer was ordered to receive Atropine Sulfate Ophthalmic Solution 0.01%, one drop by mouth as needed for secretions, up to four times daily. However, a Certified Medication Aide administered three drops instead of the prescribed one drop. Staff interviews confirmed that the expectation is to follow the five rights of medication administration, but this was not adhered to during the observed medication pass. In another case, a resident with intact cognition and a history of fracture and non-Alzheimer's dementia was prescribed Calcium 600 mg plus Vitamin D 800 units, to be taken twice daily. Instead, the resident received Calcium 600 mg with Vitamin D3 400 units due to a pharmacy dispensing error, and this incorrect dosage was administered for multiple doses. The facility's double-check system for medication orders and pharmacy deliveries was not effectively implemented, as the error was not identified before administration. The facility's medication administration policy did not clearly define acceptable standards for personnel to follow, contributing to these errors.