Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Incorrect Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with two medication errors identified out of 31 observed opportunities, resulting in a 6.45% error rate. One error involved a resident who did not receive tramadol as prescribed for moderate to severe pain because the medication was not available in the facility at the time of administration. Instead, the resident was given Tylenol, which was only indicated for lower pain levels, despite the resident reporting a pain level of 5. The nurse acknowledged that tramadol should have been available and administered according to the physician's order and facility policy. Another error occurred when a different resident received a multivitamin with minerals, contrary to the physician's order for a multivitamin without minerals. The nurse administering the medication admitted to not following the five rights of medication administration and recognized this as a medication error. The Director of Nursing confirmed that the correct form of the multivitamin was not given and that this could potentially affect the resident's health, especially considering the resident's medical condition, which included a left lower leg wound. Record reviews confirmed that both residents had clear physician orders for their respective medications, and the facility's policies required strict adherence to these orders, including ensuring medication availability and verifying the correct medication before administration. The failures were observed during medication passes and confirmed through interviews with the involved nurse and the Director of Nursing, as well as through review of the residents' medical records and the facility's policies and procedures.