Medication Error Rate Exceeds 5% Due to Incorrect Dosage and Incomplete Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 9.09% error rate as observed during medication administration by two staff members. Specifically, one medication aide administered an incorrect dose of vitamin B12 to a resident with anemia, giving a full 1000 mcg tablet instead of the ordered 0.5 tablet (500 mcg). The aide admitted to not reviewing the physician's order prior to administration and was unaware of the correct dosage, leading to the resident not receiving the intended therapy. Another incident involved a nurse administering medications via gastrostomy tube to a newly admitted resident with a history of stroke and dysphagia. The nurse failed to ensure all crushed medication was delivered, leaving residue in the medication cups, and did not flush the tube with the prescribed amount of water before and after administration. The nurse acknowledged not reviewing the physician's orders and was aware that not all medication was administered, which could result in the resident not receiving the full therapeutic dose. Interviews with facility leadership, including the ADON and Interim DON, confirmed that staff are expected to review physician orders and ensure complete administration of medications, especially for residents with g-tubes. The facility's policies also require verification that medication cups are clear of remnants and that the correct flushing protocol is followed. However, these protocols were not adhered to during the observed medication passes, contributing to the elevated medication error rate.