Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by seven errors out of 26 observed medication administration opportunities, resulting in an error rate of 26.9%. For one resident with chronic atrial fibrillation, cerebrovascular disease, hypertension, congestive heart failure, and diabetes mellitus, a registered nurse administered prescribed morning medications outside the required timeframe. The nurse acknowledged administering the medications late, citing unfamiliarity with the hallway and being behind schedule. For another resident with dementia, diabetes mellitus, hypertension, anxiety disorder, and major depressive disorder, an LPN prepared and initially administered incorrect dosages of buspar and Effexor, and provided enteric coated aspirin instead of the ordered chewable form. The LPN confirmed the errors after being questioned and corrected the dosages, and later obtained the correct form of aspirin from the supply cabinet. Facility policy required medications to be administered as ordered and within a specific timeframe, which was not followed in these instances.