Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication administration pass, resulting in a 10.7% error rate. Out of 28 medication administration opportunities observed, three errors were identified for one resident. The errors included administering Gabapentin and Calgest (TUMS) together despite a warning label instructing not to give Gabapentin with aluminum/magnesium antacids within two hours, administering only one tablet of Levetiracetam instead of the ordered three tablets, and failing to administer a prescribed Calcium 600 mg + D3 200 mg tablet because it was not available from the pharmacy. The resident involved was documented as cognitively intact and had specific physician orders for multiple medications. The LPN responsible for the medication pass admitted to not reading the Gabapentin label, being in a hurry and not administering the correct dose of Levetiracetam, and not providing the Calcium + D3 tablet due to its unavailability. Facility policy requires verification of medications with physician orders and checking medication labels at least three times for safety and accuracy, which was not followed in these instances.