Medication Error Rate Exceeds Acceptable Threshold Due to Dose Verification and Administration Failures
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5%, as evidenced by a calculated error rate of 14.29% during surveyor observation. Two of four licensed nurses were observed making medication administration errors involving two residents. One nurse administered docusate sodium to a resident without verifying the specific dose, as the physician's order and the Medication Administration Record (MAR) both lacked a specified dosage. The nurse assumed the correct dose was 100 mg, based on available stock, and administered it without clarification from the physician, despite acknowledging that other dosages exist and that clarification should have been sought. Another nurse failed to ensure the full dosages of three out of nine prescribed medications were administered to a different resident. After administering the medications via gastrostomy tube (GT), inspection of the medication cups revealed residue of aspirin, vitamin D3, and multivitamins with minerals, indicating incomplete administration. The nurse verified the presence of residue in the cups after administration, confirming that the resident did not receive the full prescribed doses of these medications. The facility's policies and procedures require verification of medication orders, including dose, prior to administration, and proper preparation and administration of medications through enteral tubes. Both nurses failed to adhere to these protocols, resulting in medication errors that were directly observed and confirmed through interviews and record reviews. The Director of Nursing acknowledged these findings and confirmed that medication doses must be specified and verified before administration.