Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by three separate incidents involving medication administration errors. In one instance, a registered nurse administered a multi-vitamin tablet without minerals to a resident, despite the physician's order specifying a multi-vitamin with minerals. The nurse later discovered the correct medication in the medication cart but had not noticed it earlier due to similar packaging. In another case, a licensed vocational nurse did not administer a prescribed chlorhexidine gluconate solution for oral care to a resident during the morning medication pass, only preparing it after the omission was identified during review. Additionally, a licensed vocational nurse failed to obtain a resident's blood sugar at the ordered time of 7 a.m., instead performing the test later in the morning and administering insulin based on the delayed reading. The nurse acknowledged missing the scheduled time and was unaware of the resident's insulin order for that morning. The facility's policy requires medications to be administered in accordance with prescriber orders and within one hour of the prescribed time unless otherwise specified.