Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a calculated error rate of 7.69% based on two errors out of 26 observed opportunities. During medication administration, a registered nurse (RN) administered Genteal moisturizing eye drops instead of the Genteal moisturizing gel as ordered by the physician for a resident with dry eyes. The nurse did not clarify the discrepancy with the physician before administering the medication, despite the order specifying the gel formulation. Additionally, the same RN attempted to administer a scheduled dose of Calcium Carbonate chewable tablet to the resident, who declined to take it and requested to keep it at her bedside for later self-administration. The RN left the medication at the bedside and documented it as administered in the medication administration record (MAR), even though the resident had not taken it. The resident had not been assessed or authorized by a physician for self-administration of medications. Interviews with staff confirmed that the nurse should have clarified the medication order and should not have documented the medication as administered without witnessing its consumption.