Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate during a medication administration observation. During a medication pass, an LPN administered Acetaminophen 500 mg (2 tablets) to a resident, despite the resident's medication administration record (MAR) specifying Acetaminophen 325 mg (2 tablets) every 6 hours as needed. Additionally, the resident was scheduled to receive Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg at 9:00 AM, but this medication was not administered during the observed medication pass. The LPN confirmed that she had completed the morning medication administration for the resident without giving the scheduled Bactrim dose. Upon later review, the LPN stated she did not initially see the Bactrim order in the MAR and only noticed it after checking the facility's 24-hour communication report. She then administered the Bactrim at approximately 10:30 AM, after the surveyor had left the area. Facility policy requires medications to be administered as prescribed, with verification of the five rights (right resident, drug, dose, route, and time) at multiple steps, and comparison of the MAR with medication labels prior to administration. The failure to follow these procedures led to the medication errors identified during the survey.