Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5.00%, as evidenced by two errors identified out of twenty-eight medication administration opportunities, resulting in a 7.14% error rate. During observation, a registered nurse dispensed medications for a resident, including Losartan, Lidocaine patch, Zonisamide, Nifedipine, and MiraLAX. The nurse placed a Losartan tablet and an unspecified amount of MiraLAX powder into the same medicine cup, then transferred both into a larger drinking cup. An additional Losartan tablet was dispensed separately, and other medications were added to the cup. Before administration, the process was stopped when it was noticed that an extra Losartan tablet had been mixed with the MiraLAX, and the nurse removed the tablet with a spoon, acknowledging the error. A review of the resident's medication orders showed that only one Losartan tablet and one packet of MiraLAX were to be administered daily. The nurse's method of measuring MiraLAX was inconsistent with the order, as she used an estimated capful rather than a specified packet, and mixed it with other medications, contrary to facility policy and the DON's expectations. The facility's policy required verification of medication name, form, dose, route, and time against the MAR, which was not followed in this instance.