Medication Error Rate Exceeds 5% Due to Incorrect Preparation and Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required, with three medication errors identified out of 35 opportunities, resulting in an error rate of 8.57%. One error involved a resident who was administered Sodium Chloride in crushed form through a G-tube, despite staff uncertainty about whether this medication should be crushed or dissolved in water. The LPN responsible for the medication pass prepared and administered the medication in a manner inconsistent with proper protocol, as confirmed by the RN Supervisor who indicated the medication should likely have been dissolved. Two additional errors were observed during the medication administration for another resident. The RN administered only 2,000 units of vitamin D instead of the ordered 10,000 units, and provided a multivitamin with minerals that did not match the physician's order for an adult multivitamin containing specific components such as vitamin K and iron. The discrepancies were confirmed through review of the physician's orders and the medication bottles, and staff interviews revealed a lack of clarity regarding the correct medications to be administered.