Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, as evidenced by a 10% error rate observed during medication administration. Specifically, three out of thirty medication administration opportunities resulted in errors involving three residents and two staff members. For two residents with severe cognitive impairment, staff administered chewable aspirin tablets without instructing or ensuring the residents chewed them, resulting in the tablets being swallowed whole. In another instance, a resident was given a higher dose of cholecalciferol (Vitamin D3) than ordered, receiving 125 mcg (5000 IU) instead of the prescribed 50 mcg (2000 IU). Record reviews confirmed that the medication orders were clear regarding the form and dosage to be administered, and medication administration records matched these orders. Observations showed that staff did not follow the specific administration instructions, and interviews with facility leadership and staff confirmed ongoing education and competency checks related to medication administration. However, these measures did not prevent the observed errors, which were directly related to staff actions during medication pass.