Medication Error Rate Exceeds 5% Due to Incorrect Drug Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 31 observed opportunities, resulting in a 9.68% error rate. In one instance, a resident with hypertension and heart failure was administered benazepril 40 mg instead of the ordered 20 mg, and was also given vitamin C 500 mg, which was not prescribed, instead of the ordered calcium 500 mg. The nurse involved acknowledged the errors after reviewing the resident's physician orders and medication packaging, confirming that the medications administered did not match the orders. In another case, a resident with a history of surgical aftercare and chronic lymphocytic leukemia was prescribed morphine sulfate ER 15 mg every 12 hours for pain management. During medication administration, the nurse gave the resident morphine IR 15 mg instead of the prescribed extended-release formulation. The nurse confirmed the discrepancy after reviewing the medication packaging and physician orders. These errors were directly observed during medication passes and confirmed through interviews and record reviews.