Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with three medication errors observed out of 25 opportunities, resulting in a 12% error rate. During medication administration, a registered nurse gave a resident an iron pill from a bottle that lacked a manufacturer's expiration date. The nurse was unaware of the significance of the handwritten date on the bottle and administered the medication without verifying its expiration, then returned the bottle to the medication cart for future use instead of disposing of it. In another instance, an LPN administered Senna Plus 8.6/50 mg to a resident, despite the physician's order not specifying a dose for Senna. The LPN stated she gave the combination medication because the order did not indicate a specific dose. Additionally, another LPN was observed preparing to administer Losartin 50 mg to a resident without initially checking for blood pressure parameters, only discovering the parameters after reviewing the physician's orders. These actions contributed to the facility's elevated medication error rate.
Plan Of Correction
F759 – Free of Medication Error Rates = 5% Element #1: On 5/27/2025, the licensed nurse involved in the medication error received immediate re-education on proper medication administration protocols and documentation. Element #2: A full-house audit was conducted to ensure expired medications are disposed of appropriately, and that medication orders are complete to include dosage and parameters if necessary. Element #3: The Administrator reviewed the policy on Medication Administration and revised as necessary. Licensed Nurses were re-educated on the policy and procedure for medication administration. Element #4: The Director of Nursing and/or designee will perform 5 random medication administration observations weekly for 12 weeks. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025