Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 17.86%. During medication administration observations, five errors were identified out of 28 opportunities, affecting two residents. Facility policy required medications to be administered safely, timely, and as prescribed, with staff expected to verify the right resident, medication, dose, route, time, and method through multiple checks before administration. For one resident with a history of essential hypertension and intact cognition, the nurse administered enteric coated aspirin instead of the prescribed chewable aspirin for DVT prophylaxis. The nurse acknowledged the need to ensure the correct medication and perform multiple checks, as outlined in facility policy. Interviews with nursing leadership confirmed expectations for thorough verification and adherence to the six rights of medication administration, including comparing medication labels with the eMAR and ensuring residents receive the correct medications as ordered. Another resident, with a history of hypertension, asthma, and moderate cognitive impairment, did not receive four prescribed medications during the observed medication pass. The nurse omitted famotidine, fluticasone, lactobacillus, and loratadine, all of which were active orders. Nursing leadership reiterated the importance of line-by-line checks against the MAR and counting medications to ensure accuracy. The administrator stated an expectation for a 0% medication error rate and emphasized the need for nurses to be thorough in medication administration.