Medication Error Rate Exceeds 5% Due to Failure to Follow Medication Orders and Procedures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 4 errors out of 37 opportunities, resulting in a 10.81% error rate. Staff did not follow policy and procedures for medication administration, including ensuring that medication orders included a prescribed dose and verifying the correct medication, dose, and form before administration. In one instance, an LPN prepared to administer only 20mg of Escitalopram to a resident whose order required a total daily dose of 30mg, as specified in the physician order sheet and EMAR. The nurse confirmed the discrepancy after being questioned by the surveyor. Another LPN dispensed an enteric-coated Aspirin 81mg tablet to a resident whose order specified a chewable form, and the nurse confirmed the difference between the prescribed and dispensed forms after reviewing the EMAR. Additionally, a third nurse prepared to administer a 500mg Calcium Carbonate tablet to a resident whose order was for 600mg with Vitamin D, and also administered a Lactobacillus capsule without a specified dose in the order. The medication administration policy required verification of the right medication, dose, route, resident, and time, and checking orders in case of discrepancies, but these procedures were not followed.