Medication Error Rate Exceeds Acceptable Threshold Due to Early Administration Attempt
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a rate of 7.69%. This was identified through observation, interview, and record review, where two medication errors occurred out of 26 opportunities. Specifically, a Licensed Vocational Nurse (LVN) prepared and attempted to administer a multivitamin and vitamin D to a resident at 8:30 AM, despite the physician's order specifying administration at 12:00 PM. The resident refused the medications, stating they were not scheduled to be given until later. Review of the resident's records indicated a history of paranoid schizophrenia and fluctuating capacity to understand and make decisions. The LVN acknowledged the error, stating that medications should be administered within one hour of the prescribed time, as per facility policy and physician orders. The facility's policy requires medications to be given only as prescribed, and the deviation from this protocol led to the cited deficiency.