Medication Error Rate Exceeds Acceptable Threshold During Medication Pass
Penalty
Summary
During a medication administration observation, an LPN failed to administer multiple ordered medications to four residents during a morning medication pass. Specifically, the LPN did not provide antihistamines to two residents, and omitted antihistamine, laxative solution, and eye drops for another resident. For a fourth resident, the LPN failed to administer vitamin C, ferrous sulfate elixir, a multivitamin, protein oral liquid, zinc, and a laxative. These omissions were observed during 42 medication administration opportunities, resulting in 11 medication errors and a medication error rate of 26.19%. The LPN initially indicated that all medications due had been administered, but upon review of the Medication Administration Record (MAR), confirmed that the omitted medications were not given, stating she did not scroll to see those orders. The MAR had been marked as if the medications were administered. The facility's policy requires medications to be administered according to prescriber orders and proper medication administration practices. The administrator confirmed that staff are expected to follow these procedures.