Medication Error Rate Exceeds 5% Due to Missed and Withheld Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate during 28 observed medication administration opportunities. Specifically, three medication errors were identified involving two residents. For one resident with atrial fibrillation and cerebral infarction, the nurse withheld Apixaban due to the medication being out of stock and not reordered in a timely manner, and also withheld Amiodarone based on a blood pressure reading, despite there being no physician-ordered parameters for withholding the medication. The nurse confirmed that the process was to order medications before running out, but this was not followed, leading to missed doses. For another resident with cirrhosis, the nurse was unable to administer Xifaxan because it was not available in the medication cart or emergency stock, and had not been reordered before supplies were depleted. The facility's policy required medication carts to be adequately stocked and medications to be held only when physician-ordered parameters were not met. The DON confirmed that medications should have been ordered in advance to prevent missed doses, and that the facility relied on a local pharmacy for same-day delivery of out-of-stock medications.