Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in a 7.69% error rate with 2 errors out of 26 observed medication administration opportunities. During medication administration, a nurse crushed and combined two medications—metoprolol tartrate and atorvastatin calcium—before administering them together via a feeding tube to a resident who was unable to swallow following a stroke. The facility's policy, dated March 2023, specified that crushed medications should not be combined for administration, whether given orally or through a feeding tube. The nurse acknowledged not being aware of this policy and administered the medications together, contrary to the physician's orders and facility protocol. The Director of Nursing confirmed that medications should be given separately with flushes between each.