Medication Error Rate Exceeds 5% Due to Omitted Doses
Penalty
No penalty information released
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Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by 2 errors out of 27 observed medication administration opportunities, resulting in a 7 percent error rate. During a medication pass, a Licensed Practical Nurse (LPN) was unable to administer Vitamin D-2 400 units to one resident and Farxiga 10 mg to another resident because both medications were not available on the medication cart or in the facility at the time of administration. These omissions were confirmed by the LPN and verified through review of the physician's orders, which indicated that both residents were to receive these medications daily. The lack of medication availability directly led to the errors by omission.