Medication Error Rate Exceeds 5% Due to Omitted Doses and Inaccurate MAR Documentation
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications as ordered to a resident with diagnoses including dementia, atrial fibrillation, and a history of venous thrombus and embolism. The resident, who was severely cognitively impaired and required significant assistance with daily activities, had physician orders for Aspirin EC 81mg once daily for atrial fibrillation and Miralax 17 grams twice daily for constipation. During a medication administration observation, the nurse prepared and dispensed all scheduled oral medications except for the Aspirin and Miralax, which were omitted from the administration. Despite not administering these medications, the nurse signed the Medication Administration Record (MAR) indicating that both Aspirin and Miralax had been given. The nurse later acknowledged that she had forgotten to administer the medications and had signed the MAR in error. Facility policy requires that all medications be administered safely and accurately in accordance with physician orders, and the omission resulted in a medication error rate of 7.14%, exceeding the acceptable threshold.