Medication Error Rate Exceeds 5% Due to Omitted Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6% error rate during the survey period. Specifically, two medications—Lactobacillus and D-Mannose—were not administered to a resident as ordered. Observation revealed that the medication aide (MA) prepared and dispensed nine medications to the resident but omitted the two required medications, which were later found to be stored in the refrigerator and not retrieved during the medication pass. The MA confirmed during interview that these medications were active orders and acknowledged not administering them because they were not taken out of the refrigerator. The resident involved had multiple diagnoses, including mood disorder, hypertension, presence of a cardiac pacemaker, congestive heart failure, and a history of urinary tract infection. The facility's policy required staff to verify each medication against the Medication Administration Record (MAR) and to check off each medication as it was dispensed. The Director of Nursing (DON) stated that following this process would have prevented the omission, as the system highlights each medication as it is administered. The failure to follow established procedures led to the omission of the two medications.