Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required by policy, resulting in a calculated error rate of 7.69 percent. This was determined through observations, staff and resident interviews, and record reviews. For one resident with diagnoses including hyperkalemia, acute kidney failure, and encephalopathy, an LPN crushed and administered atorvastatin calcium oral tablet, despite the medication not being approved for crushing. The LPN acknowledged the error, and the facility pharmacist confirmed that atorvastatin calcium tablets should not be crushed. The Director of Nursing also confirmed that nurses are expected to follow the facility's policy and reference materials regarding medication administration. In another instance, a resident with a history of hemiplegia, hemiparesis, dysarthria, anarthria, and muscle weakness was ordered to receive one scoop of polyethylene glycol powder daily for constipation. However, an LPN administered two scoops after the resident requested an additional dose, without provider approval. The LPN confirmed the deviation from the physician's order, and the Director of Nursing stated that any changes to medication administration require prior provider approval. These actions directly contributed to the facility's medication error rate exceeding the acceptable threshold.