Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as required, with 3 errors identified out of 33 opportunities, resulting in a 9.09% error rate. One incident involved a nurse administering Senna 8.6 mg tablets and Folic Acid 800 mcg to a resident, instead of the prescribed Senna S (Sennosides-Docusate sodium) 8.6-50 mg and Folic Acid 1 mg. The nurse confirmed to the surveyor and the Director of Nursing that the medications given did not match the physician's orders, and documentation showed the resident had moderate cognitive impairment and multiple diagnoses, including chronic ulcers and swelling in the lower limbs. Another error occurred when a registered nurse administered Calcium Carbonate 500 mg (Alkums Antacid) to a different resident, instead of the ordered Calcium Carbonate-Vitamin D 500-200 mg. The product given did not contain vitamin D, as required by the physician's order. This resident was cognitively intact and had diagnoses including hypokalemia, hyponatremia, and hypertension. Facility policy and job descriptions require staff to administer medications as prescribed and verify medications before administration, but these procedures were not followed in the cited instances.