Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, resulting in a medication error rate of 10.3%, which exceeds the acceptable threshold of less than 5%. Specifically, a resident with a history of left femur fracture, arthritis, hyperlipidemia, cerebrovascular disease, and dysphagia was observed to have received medications that had been discontinued by physician order. Despite a pharmacy recommendation and a signed physician order to discontinue Colace and tamsulosin, these medications continued to be administered for several days. Additionally, the resident was given aspirin 81 mg instead of the prescribed aspirin-dipyridamole 25-100 mg tablet. During medication administration observation, a registered nurse prepared and administered Colace, tamsulosin, and aspirin 81 mg to the resident, contrary to the current physician orders. Interviews with nursing and clinical leadership confirmed that the discontinued medications were still being given and that the wrong form of aspirin was administered. Review of facility policy indicated that staff are required to verify medication orders and ensure correct administration, but these procedures were not followed, leading to the identified medication errors.