Medication Error Rate Exceeds Acceptable Threshold
Penalty
No penalty information released
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Summary
A medication error rate of 7.14% was identified during a survey, with 2 errors observed out of 28 medication administration opportunities, affecting one resident. The facility's policy required staff to obtain and record vital signs and to hold medications if the resident's vital signs were outside physician-prescribed parameters. On the observed occasion, a registered nurse prepared Amoxicillin and Carvedilol for a resident whose blood pressure and heart rate were below the parameters set for Carvedilol administration. The nurse also prepared an incorrect dose of Amoxicillin. The surveyor intervened before the medications were administered, prompting the nurse to review the orders and acknowledge the errors.