Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with nine errors identified out of 26 opportunities, resulting in a 34.6% error rate. For one resident with schizophrenia, paraplegia, congestive heart failure, and anxiety disorder, staff crushed and administered Aripiprazole despite clear pharmacy labeling and manufacturer guidance stating the medication should not be crushed. The LPN involved confirmed the error during an interview. Another resident with anxiety, Alzheimer's disease, hypertension, and psychosis did not receive the full dose of multiple medications, as the LPN discarded the remaining crushed and liquid medications after partial administration. The LPN was unable to specify which medications or how much was not given. Additionally, a resident with congestive heart failure received crushed Sacubitril-Valsartan (Entresto), contrary to manufacturer guidelines, which recommend against crushing the tablet and suggest alternative forms if swallowing is an issue. These events were observed and verified through staff interviews and review of relevant policies and manufacturer instructions.