Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as three medication errors were observed out of 25 opportunities, resulting in an 8% error rate. One incident involved an intravenous (IV) antibiotic, Meropenem, which was mixed by an LPN during the night shift and left hanging in a resident's room from approximately 6:00 AM until after 11:00 AM, when it was administered by another LPN. The medication was signed out as given at 6:00 AM, despite not being administered until much later. Both LPNs involved acknowledged the delay and improper handling of the medication, with the IV bag left unattended in the resident's room for several hours. Another incident involved a resident who had three white tablets and a green Tums tablet left at the bedside by the night nurse, despite no physician order for Tums and no standing order for medications to be left at the bedside. The resident reported that the night nurse provided the tablets to moisturize her mouth. Additionally, levothyroxine was administered to the same resident with breakfast and other medications, contrary to guidelines that require it to be given on an empty stomach. These actions were observed and confirmed by staff interviews and record reviews, demonstrating non-compliance with the facility's medication administration policies.