Medication Error Rate Exceeds 5% Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by four errors out of 27 observed opportunities during medication administration for three residents. For one resident with schizophrenia, a licensed nurse did not administer the prescribed dose of haloperidol as ordered, due to a discrepancy between the physician's order and the available medication dose in the facility. The nurse withheld the medication pending clarification, and it was confirmed that the correct dose should have been available for administration according to the physician's order and facility policy. Another resident with epilepsy was administered divalproex sodium by a licensed nurse who failed to wear gloves, despite the medication label and physician order specifying glove use due to the hazardous nature of the drug. The nurse acknowledged the omission and the reason for the glove requirement. The facility's policy also required adherence to manufacturer specifications and physician orders during medication administration. A third resident, a transplant recipient, was administered mycophenolate without the nurse wearing gloves, contrary to both the medication label and physician order, which required glove use. Additionally, this resident did not receive the prescribed aspirin during the observed medication pass, and the nurse was unable to clarify the timing or reason for the missed dose. The DON confirmed that the expectation was for nurses to follow the e-MAR and physician orders, and that the aspirin should have been administered as ordered.