Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Improper Administration
Penalty
Summary
A medication error rate of 12% was identified during a medication pass, with three errors observed out of 25 opportunities involving three residents. One resident did not receive their prescribed Calcium Carbonate with Vitamin D tablet as ordered by the physician because the medication was not available at the time of administration. Another resident received Diroximel Fumarate capsules, a medication for multiple sclerosis, without food, contrary to the physician's order and manufacturer instructions that specify the medication should be administered at least 20 minutes after food intake. The nurse did not verify if the resident had eaten prior to administration. Additionally, a third resident did not receive their prescribed Fluticasone-Salmeterol inhalation for asthma as ordered, as the medication was not available during the scheduled medication pass. In each case, the medications were not administered in accordance with physician orders and manufacturer specifications, as confirmed by concurrent interviews and record reviews with the Director of Nursing. Facility policy requires medications to be administered as ordered by the physician and in accordance with professional standards of practice.