Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of eight percent during a recertification survey. Specifically, two out of four residents observed during a medication pass experienced medication errors. For one resident with diagnoses including squamous cell carcinoma, depressive disorder, and urinary tract infection, an LPN selected the wrong medication (Doxycycline instead of the prescribed Duloxetine) from the medication cart, though the error was identified before administration. The resident was noted to be cognitively intact and able to communicate effectively. For another resident with type 2 diabetes, dementia, and depression, an LPN opened and poured out the contents of a Duloxetine delayed-release capsule, contrary to manufacturer guidelines that specify the capsule should not be opened, crushed, or mixed with food or liquids. The resident had severe cognitive impairment but could usually be understood. The LPN stated that all medications for this resident were crushed, and the DON confirmed that the pharmacy or physician should have been notified to prescribe an alternative form if crushing was necessary. These actions were inconsistent with both facility policy and manufacturer instructions, leading to the cited deficiency.