Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
A medication error rate of 9.68% was identified during medication administration observations, with three errors out of 31 opportunities involving two residents. For one resident with type 2 diabetes and diabetic neuropathic arthropathy, a licensed vocational nurse failed to administer both gabapentin, prescribed for nerve pain, and docusate sodium, prescribed for constipation, at the scheduled 9:00 a.m. medication pass. The nurse later confirmed the omission upon review of the medication administration record and acknowledged the error. In a separate incident, another resident was administered Xarelto 20 mg, an anticoagulant, without food, despite the physician's order specifying it should be taken with dinner. The nurse verified the order required administration with food in the evening, and both the regional nurse consultant and pharmacy consultant confirmed that the medication should be given as ordered and in accordance with manufacturer guidelines. Facility policy also requires medications to be administered as ordered and per manufacturer specifications.