Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with two medication errors identified out of 34 opportunities, resulting in an 8.82% error rate. One error involved a nurse administering carvedilol to a resident with hypertension at a time inconsistent with the physician's order, which specified administration at 8 a.m. with food. The nurse acknowledged administering the medication outside the facility's 60-minute window for scheduled medications, as outlined in facility policy, and recognized this as a medication error. Another resident, who had diagnoses including malnutrition and failure to thrive, did not receive docusate as ordered and was given a multivitamin with minerals instead of the prescribed multivitamin without minerals. The nurse responsible stated that docusate was withheld due to a soft stool, despite the order specifying to hold only for loose stools, and admitted this was an error. The nurse also acknowledged administering the incorrect form of multivitamin, contrary to the physician's order. Interviews with the Director of Nursing confirmed that these incidents were considered medication errors according to facility policy and procedures. Documentation review supported that the medications were not administered as prescribed, and the facility's policies require strict adherence to physician orders and scheduled administration times.