Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy, with an observed error rate of 7.14%. During a medication administration observation, one of two licensed nurses, LVN 7, did not administer medications according to physician orders for a resident. Specifically, LVN 7 administered sevelamer, a phosphate binder, after the resident had already eaten breakfast, rather than with the meal as ordered. Additionally, LVN 7 did not administer furosemide, a diuretic prescribed for edema, during the medication pass and did not clarify the omission with the physician, despite the medication's indication being for edema and not hypertension. Medical record review confirmed the active orders for both sevelamer and furosemide, and interviews with LVN 7 and the DON verified that the medications were not administered as prescribed. LVN 7 acknowledged the errors, stating she withheld furosemide due to concerns about blood pressure before dialysis, even though the order was for edema. The facility's policy requires medications to be administered as prescribed and in accordance with physician orders, which was not followed in these instances.