Medication Error Rate Exceeds 5% Due to Incorrect Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors identified out of 33 observed opportunities, resulting in a 6.06% error rate. In the first instance, a nurse administered the incorrect dose and form of docusate sodium to a resident. The resident was ordered to receive docusate sodium 100 mg oral tablet four times daily, but instead received a 250 mg capsule. The nurse did not verify the resident’s identity through standard procedures such as checking the identification bracelet or confirming the resident’s name and date of birth prior to administration. The nurse later acknowledged the error and confirmed that the medication given did not match the physician’s order. In the second instance, a nurse failed to check a resident’s heart rate prior to administering amiodarone 200 mg, as required by the physician’s order, which specified to hold the medication if the heart rate was less than 60 bpm. The nurse stated that vital signs were checked earlier in the morning but were not documented until after medication administration. The nurse admitted that the heart rate should have been checked immediately before giving the medication, in accordance with the order’s parameters. The resident’s care plan and physician’s order both indicated the necessity of monitoring vital signs prior to administration of cardiac medication. Both incidents were observed during medication administration and were confirmed through interviews with the involved nurse and the Director of Nursing. The facility’s policy and procedures require that medications be administered only as prescribed, with proper resident identification and completion of any required vital sign checks prior to administration. The observed practices did not align with these requirements, resulting in the cited deficiencies.