Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 33 observed opportunities during medication administration, resulting in a 9.09% error rate. In one instance, a nurse did not administer doxazosin 2 mg to a resident as ordered at 9 AM, because the medication was not found in the cart at the time of administration. The medication was later located in a drawer designated for evening medications. In another case, a nurse did not apply diclofenac sodium gel to a resident's right shoulder as ordered, stating that the resident did not request it, despite the order not being PRN (as needed). Additionally, a nurse applied diclofenac gel to a resident's knees instead of the hands as prescribed, following the resident's request, which was not in accordance with the written order. These incidents were observed during medication passes and confirmed through interviews and record reviews. The facility's policy requires medications to be administered as prescribed, including verifying the correct dosage, time, and route, but these procedures were not consistently followed, leading to the identified medication errors.