Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Errors
Penalty
Summary
The facility failed to ensure that its medication error rate remained below five percent, as required. During medication administration observations, three errors were identified out of 26 opportunities, resulting in an error rate of 11.54%. These errors involved two residents who were administered medications that did not match their physician's orders. Specifically, one resident received an incorrect dose of calcium carbonate, and another received both the wrong formulation of a multivitamin and an incorrect dose of Seroquel. For the first resident, the nurse administered a 750 mg tablet of calcium carbonate instead of the prescribed 500 mg dose. The resident had a history of paranoid schizophrenia and was capable of making her own medical decisions. The error was observed during the medication pass, and the nurse later acknowledged administering the incorrect dose. The second resident, who also had a diagnosis of schizophrenia and was capable of medical decision-making, was given a multivitamin with minerals instead of the prescribed formulation without minerals. Additionally, the nurse administered a full 50 mg tablet of Seroquel instead of the ordered half-tablet dose. The nurse stated that she did not verify the medication label against the physician's order and failed to notice a discrepancy between the pharmacy label and the current order, which contributed to the administration of the incorrect dose and formulation.