Medication Error Rate Exceeds Acceptable Threshold Due to Missed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, during a medication administration observation. Out of 33 opportunities for medication administration, two errors were identified, resulting in a medication error rate of 6.06 percent. The errors involved a Licensed Vocational Nurse (LVN) not administering cholecalciferol and Miralax to a resident as ordered by the physician during the scheduled medication pass. The resident involved had a complex medical history, including a gastrostomy tube, respiratory failure, and a peritoneal abscess, and was assessed as having moderately impaired cognitive skills and being dependent on staff for all activities of daily living. The resident's medication orders included cholecalciferol and Miralax to be administered via G-tube once daily at 9 AM, along with other medications. During the observed medication pass, the LVN administered all other scheduled medications but omitted cholecalciferol and Miralax. Upon review, the LVN acknowledged not realizing the omission at the time and stated that medications could be given within a one-hour window before or after the scheduled time. The Director of Nursing confirmed that the LVN should have followed the physician's orders and administered all medications as scheduled. Facility policy required medications to be administered safely, timely, and as prescribed, which was not followed in this instance.