Medication Error Rate Exceeds 5% Due to Omission and Wrong Dosage
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 31 opportunities during a medication pass for one resident. The first error involved the omission of a prescribed Cyanocobalamin (Vitamin B12) tablet, which was not administered to a resident with chronic obstructive pulmonary disease (COPD) and anemia, despite an active physician's order. Nurse #1, who was responsible for the medication pass, confirmed during an interview that she missed giving the Cyanocobalamin tablet and it was not included among the medications administered. The second error occurred when Nurse #1 administered the wrong dosage of Guaifenesin, giving a 400 mg tablet instead of the ordered 600 mg extended-release tablet for COPD. Nurse #1 stated that she used what was available from the stock bottle, which only contained 400 mg tablets, and did not realize the discrepancy at the time of administration. The Director of Nursing confirmed that Guaifenesin is typically available in different strengths and that the correct dosage could have been ordered from the pharmacy if not in stock. Nurse #1 was newly assigned to the medication cart after several weeks of orientation.