Medication Error Rate Exceeds 5% Due to Dosage Calculation and Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during the survey period. Licensed nurses did not identify a discrepancy between the medication on hand and the medication ordered by the physician for one resident. Specifically, the medication available was Polyethylene Glycol 3350, while the order was for Polyethylene Glycol 1450, and the nurses did not clarify this difference with the physician before preparing the medication. Additionally, three licensed vocational nurses were unable to correctly perform basic nursing dosage calculations, such as converting ounces to milliliters and tablespoons to milliliters. During medication administration, one nurse used a plastic spoon instead of a proper measuring tool to measure a powdered medication and did not use any measuring tools to accurately measure the prescribed amount of water. When questioned, the nurses were unable to provide correct answers for basic dosage conversions and did not demonstrate knowledge of proper measurement techniques. The residents involved had significant medical conditions and were completely dependent on staff for care, with documentation indicating severely impaired cognition and lack of capacity to make medical decisions. The facility's policy required medications to be administered as prescribed and in accordance with orders, but this was not followed during the observed medication passes.