Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure that staff administered medications with an error rate below five percent, as required. During observation, three medication errors were identified out of 24 opportunities, resulting in a 12.5 percent error rate. Specifically, a registered nurse administered two tablets of metoprolol tartrate 25 mg instead of the prescribed one tablet to a resident with chronic respiratory and cardiac conditions. The nurse later confirmed the error during an interview. Additionally, another resident with multiple chronic conditions, including hypertensive heart failure, bipolar disorder, and diabetes, received an incorrect dosage of cyanobalamin (500 mcg instead of the ordered 1000 mcg) and did not receive the prescribed vitamin D2 50 mcg tablet. The nurse responsible acknowledged both the incorrect dosage and the omission of the vitamin D2 medication. These incidents were observed and verified through record review and staff interviews, demonstrating non-compliance with the facility's medication administration policy.