Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with a calculated error rate of 7% based on 2 errors out of 27 observed medication administrations. During medication administration, a Certified Medication Aide (CMA) prepared and administered Vitamin D to a resident, but the order specified Vitamin D3, 25 mcg, indicating the wrong formulation was given. In another instance, the CMA administered Atenolol 50 mg to a different resident despite the order specifying the medication should be held if the resident's pulse was below 60 beats per minute; the resident's pulse was documented at 53 at the time of administration. The facility's policy requires medications to be administered according to physician orders and for staff to verify the drug and dosage against the Medication Administration Record (MAR) and drug label prior to administration. Staff interviews confirmed the errors, with the CMA acknowledging the administration of the incorrect Vitamin D formulation and the failure to hold Atenolol as ordered. The errors were observed and verified through direct observation, record review, and staff interviews.