Medication Error Rate Exceeds 5% Due to Failure to Administer Medications With Food
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, when a Licensed Vocational Nurse (LVN) did not administer medications according to physician orders for two out of five randomly selected residents. Specifically, the LVN did not ensure that metoprolol for one resident and aspirin for another were given with food, as directed by the prescribers. This resulted in two medication errors out of 30 opportunities, yielding a medication administration error rate of 6.67%. For the first resident, who had diagnoses including hypertensive heart disease with heart failure and paroxysmal atrial fibrillation, the physician's order specified that metoprolol should be administered with food or after meals. During medication administration, the LVN checked the resident's vital signs but did not ask if the resident had eaten or offer a snack before giving the medication. The LVN later acknowledged not following the order to give the medication with food, which could help prevent stomach discomfort. For the second resident, who had a history of stroke, hemiplegia, and malignant neoplasm of the brain, the order for aspirin also specified administration with food. The LVN did not verify if the resident had eaten or offer a snack prior to giving the medication. The LVN confirmed during an interview that the order was not followed. The Director of Nursing stated that nurses are responsible for reviewing and carrying out all medication order instructions, including ensuring medications ordered with food are administered accordingly.