Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by three medication errors out of 30 opportunities observed for two residents. For one resident, physician orders indicated daily administration of amlodipine besylate and atorvastatin calcium, both scheduled for the morning. On the day of observation, these medications were unavailable for administration, and the Certified Medication Technician (CMT) reported the issue to the Licensed Practical Nurse (LPN), who was to locate or order the medications from the pharmacy. The CMT confirmed that the amlodipine had been ordered previously. For another resident, physician orders required daily administration of Tiadylt ER 24-hour oral 180 mg capsule, also scheduled for the morning. During observation, this medication was not available for administration and was not present in the emergency medication stock. The CMT confirmed the unavailability, and later, the Director of Nursing (DON) and Corporate Nurse stated that staff should obtain medications from the emergency supply if not available on the cart. These events resulted in a medication error rate of 10 percent, exceeding the acceptable threshold.