Medication Error Rate Exceeds 5% Due to Incorrect Dose, Route, and Lack of Monitoring
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with four errors identified in 35 opportunities, resulting in an error rate of 11.43%. One staff member, an LVN, administered 325 mg of Aspirin crushed via PEG tube to a resident, despite the order specifying 81 mg chewable Aspirin to be given by mouth. The same resident, who had a history of cerebral infarction, dysphagia, aphasia, and essential hypertension, was also not assessed with vital signs such as blood pressure and pulse prior to receiving multiple antihypertensive medications, as required by accepted standards and the resident's care plan. The resident involved was severely cognitively impaired, non-verbal, and on an NPO diet due to dysphagia, requiring all medications to be administered via PEG tube. Despite this, the medication order for Aspirin was not clarified or updated to reflect the appropriate route, and the incorrect dose was given. Staff interviews revealed that nurses did not consistently check or document vital signs before administering blood pressure medications, and there was a lack of clarity among staff and pharmacy regarding the need for blood pressure parameters and monitoring for such residents. Facility policy required staff to verify medication orders, be aware of contraindications, and consult with prescribers if there were concerns about medication administration. However, these procedures were not followed, as staff failed to review and clarify the medication orders, did not monitor vital signs as indicated, and did not communicate concerns to the physician or pharmacy. The failure to adhere to these protocols resulted in medication errors involving incorrect dose, route, and lack of necessary monitoring for a resident with significant medical vulnerabilities.