Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician and without error, resulting in a medication error rate of 8.11%, which exceeds the acceptable threshold of 5%. Specifically, three errors were identified out of 37 medication administrations observed. One resident, who had multiple diagnoses including pneumonia, hypoxemia, diabetes, COPD, glaucoma, chronic kidney disease, and depression, was affected. This resident was assessed as having moderately impaired cognition, was dependent on staff for activities of daily living, had adequate vision with corrective lenses, and was incontinent of urine. During medication administration, a registered nurse did not administer cilostazol 100 mg as ordered because it was not available at the facility. Additionally, the nurse administered brimonidine and dorzolamide eye drops consecutively without the required pause between different eye medications, contrary to facility policy, which specifies a 3 to 5 minute interval for optimal absorption. These actions were confirmed through observation and staff interview, and were not in accordance with the facility's medication administration procedures.