Medication Error Rate Exceeds Acceptable Threshold Due to Missed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with a calculated error rate of 7.69% based on 26 observed opportunities and two errors. The errors involved two residents who did not receive their prescribed medications due to the medications being out of stock. In both cases, the registered nurses identified that the medications were not available in the medication cart and attempted to locate them in the medication storage room and automated dispensing system. When the medications were not found, the nurses indicated they would contact the pharmacy, but the medications were not administered as ordered. One resident, with a history of cerebral infarction, intracardiac thrombosis, and ventricular tachycardia, did not receive a scheduled dose of Pradaxa because it was not available in the facility. The nurse documented the medication as 'On Order' from the pharmacy but did not provide documentation of physician notification or alternative orders. Another resident, with diagnoses including obstructive and reflux uropathy and post-surgical aftercare, did not receive a scheduled dose of Finasteride for similar reasons, with the medication also marked as 'On Order' and no documentation of physician notification or alternative instructions. The Director of Nursing confirmed that there was no facility policy specifically addressing medication administration errors and that staff were expected to follow the rights of medication administration. The DON also acknowledged that there was no documentation of physician notification or pharmacy contact for the missed doses. Facility policy required medications to be administered as prescribed and for any withheld or missed doses to be documented with an explanatory note, which was not done in these cases.