Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by errors observed during medication administration for three of seven residents. One resident was administered Breo Ellipta Aerosol Powder by a licensed nurse, but the nurse did not ensure the resident rinsed and spit after inhalation, contrary to the physician's order. This step is necessary to comply with the prescribed administration method. The nurse confirmed the omission during an interview at the time of the finding. Another resident did not receive a scheduled dose of Ipratropium-Albuterol Inhalation Solution because the medication was not available in the facility, and the nurse was waiting for it to arrive from the pharmacy. Additionally, a third resident was given Aspirin Tablet Enteric Coated 81 mg instead of the prescribed Aspirin Tablet Chewable 81 mg, as per the physician's order. The nurse administering the medication confirmed this discrepancy during the observation. These incidents resulted in a calculated medication error rate of 10.34%.