Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by three medication errors out of 31 observed opportunities, resulting in a 9.68% error rate. For one resident with hypertension, bipolar disorder, and insomnia, the LPN administered both Amlodipine Besylate and Hydralazine despite the resident's blood pressure not meeting the parameters specified in the physician's orders. The blood pressure reading was 155/74 mm/Hg, which did not warrant administration of either medication according to the orders, but both were given regardless. Another resident with paroxysmal atrial fibrillation, hypertension, and a cardiac pacemaker was administered Digoxin after the LPN obtained a pulse using a pulse oximeter for less than 30 seconds, rather than obtaining an apical pulse for a full minute as required. The facility's policy requires medications to be administered safely and as prescribed, but these procedures were not followed during the observed medication passes.