Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy and regulation. During medication administration observations, two errors were identified out of 30 opportunities, resulting in a 6.67 percent error rate. The facility's policy required staff to verify the electronic medical record against the prescription label and adhere to the six rights of medication administration. However, these procedures were not followed in the observed instances. One cognitively intact resident with renal failure and peripheral vascular disease was ordered to receive 250 mg of calcium citrate twice daily but was instead administered 950 mg. Another cognitively intact resident with multiple sclerosis was ordered to receive two drops of artificial tears in each eye three times daily but was only given one drop per eye. Both errors were confirmed by the LPN involved and the Director of Nursing, who acknowledged that the medications administered did not match the physician's orders.