Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 18.75% during a medication pass, as six errors were identified out of 32 opportunities. The errors involved two residents and were discovered through direct observation, interviews, and record reviews. The facility's policy defines a medication error as any preparation or administration of drugs not in accordance with physician's orders, manufacturer specifications, or accepted professional standards. For one resident with diagnoses including protein-calorie malnutrition, dementia, and sepsis, the physician's order specified Florastor Oral Capsule 250 mg (Saccharomyces boulardii) for digestive health, which was discontinued on a certain date. However, during a medication pass, an LPN administered Lactobacillus 250 mg instead, despite there being no current order for this medication. Both the LPN and the Assistant Director of Nursing initially stated that the two medications were the same, but later clarified that they are similar but not identical. Another resident with chronic obstructive pulmonary disease, malignant neoplasm, major depressive disorder, and hypertension was observed receiving multiple medications late. The LPN administered the medications after the scheduled time but documented them as given at the scheduled time on the Medication Administration Record (MAR), without noting the actual time or the reason for the delay. The facility's policy requires documentation of late administration and the reason, but this was not followed. The Assistant Director of Nursing confirmed that such documentation was not being completed, and there were no progress notes explaining the late administration.