Medication Error Rate Exceeds Acceptable Threshold Due to Dosage and Expiration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with two medication errors identified out of 31 observed opportunities, resulting in a 6.45% error rate. In the first instance, a nurse administered an incorrect dosage of docusate sodium to a resident with chronic obstructive pulmonary disease, a history of falls, and fibromyalgia. The physician's order specified 250 mg of docusate sodium twice daily, but the nurse administered only 100 mg. This discrepancy was confirmed through record review and interviews with nursing staff and the Director of Nursing, who acknowledged that the medication was not given as ordered and that the lower dose would not be as effective in treating the resident's constipation. In the second instance, another nurse failed to check the expiration date before preparing docusate sodium for a resident diagnosed with dementia, constipation, and hypertension. The medication bottle had expired, but the nurse did not notice this until it was pointed out by the surveyor during the medication pass. The nurse admitted to not reading the expiration date, and facility staff confirmed that expired medications should not be administered due to safety concerns and potential ineffectiveness. Both incidents were observed during medication administration and were corroborated by interviews with nursing staff, the Director of Staff Development, the Infection Preventionist, and the Director of Nursing. Facility policy required medications to be administered according to prescriber orders and for expiration dates to be checked prior to administration, but these procedures were not followed in either case.