Medication Error Rate Exceeds Acceptable Threshold Due to Missed Doses and Tracking Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a calculated error rate of 13% with four errors out of 29 observed opportunities. During medication administration, staff were unable to locate prescribed medications, including Vitamin A and cranberry tablets for one resident, and amlodipine for another resident. In these instances, the medications were not administered as ordered, and in some cases, the physician was not notified of the missed doses. Additionally, an LPN mistakenly prepared simethicone instead of sodium bicarbonate for a resident, but recognized the error before administration. Interviews with staff revealed a lack of a formal system to track the availability of over-the-counter medications, and inconsistent communication regarding medication supply. The DON stated reliance on unit managers, central supply, and floor nurses to ensure medication availability, but acknowledged the absence of a structured process. The observed failures to administer medications as prescribed and to notify physicians as required contributed directly to the elevated medication error rate.