Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
A deficiency occurred when a registered nurse failed to administer medications as ordered for a resident with multiple diagnoses, including hypertension, COPD, schizophrenia, type 2 diabetes, chronic pulmonary edema, and chronic hepatitis C. During a medication pass, the nurse withheld two antihypertensive medications, Losartan Potassium and Sotalol HCl, despite the resident's blood pressure being above the physician-ordered parameters for holding the medications. The nurse did not provide an explanation for this decision, and the Director of Nursing confirmed that the medications should not have been held under the circumstances. Additionally, the nurse failed to administer the resident's prescribed dose of Furosemide after dropping the last available tablet into the medication cart drawer. The nurse did not attempt to retrieve the medication from another source, nor did she contact the pharmacy or physician for further instructions, as required by facility policy. These actions resulted in three medication errors out of 28 opportunities, leading to a medication error rate of 10.71%, which exceeds the acceptable threshold.