Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with 2 errors identified out of 37 observed medication administration opportunities, resulting in a 5.41% error rate. In one instance, an LPN administered three inhalers to a resident in the incorrect sequence, contrary to the facility's policy. The beta agonist inhaler was given first as required, but the corticosteroid inhaler was administered second instead of last, and the anticholinergic inhaler was given last instead of second. The LPN admitted uncertainty about the correct sequence and did not verify the order before administration. The Nursing Home Administrator confirmed that the facility policy was not followed in this case. In another instance, the same LPN administered Carafate to a different resident after breakfast, despite physician orders specifying that the medication should be given before meals. The LPN acknowledged the error, stating that the medication should have been administered prior to the meal but was not due to timing. The Nursing Home Administrator confirmed that the expectation was to follow the physician's order for Carafate administration before meals.