Medication Error Rate Exceeds 5% Due to Missed and Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 5.71% error rate during observed medication administration. For one resident, a prescribed daily dose of Calcium 600mg/Vitamin D 10 mcg in chewable form was not administered because the facility did not have the chewable tablets available. Additionally, the same resident's physician order for a Lidocaine 4% patch to be applied to the left leg base for 12 hours in the morning and removed in the evening was not followed; the patch was not removed after 12 hours as required. The LPN also did not date, time, or initial the Lidocaine patch upon application, as is standard practice. These actions and omissions were confirmed through staff interviews and direct observation.