Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.67% error rate during a medication pass observation. In one instance, a nurse administered both a multivitamin with iron and a separate iron replacement tablet to a resident, despite the physician's order for only one of each. The nurse acknowledged that this could result in the resident receiving too much iron and confirmed that the medication was taken from the bottle on the medication cart without verifying with the physician. In another case, a nurse administered a Vitamin D tablet at a dosage of 10 mcg instead of the prescribed 100 mcg to a different resident. Upon review, the nurse could not locate the correct dosage in the medication cart and realized that two tablets of a 50 mcg dosage should have been given to meet the physician's order. The Director of Nursing was informed of the two medication errors out of 30 opportunities, confirming the facility's medication error rate exceeded the acceptable threshold.