Medication Error Rate Exceeds Regulatory Standard
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in an observed error rate of 11.11%. This was identified through observation, interview, and record review, where three medication errors were found among twenty-seven opportunities for three residents. One resident, with intact cognition and a history of insulin use, received insulin after already consuming food, contrary to the prescribed administration of insulin before meals. Another resident, also with intact cognition and a diagnosis of anemia, was administered a 324 mg enteric-coated tablet of Ferrous Sulfate instead of the prescribed 325 mg oral tablet. A third resident, with intact cognition and a prescription for Polyethylene Glycol 1450, was given Clearlax 3350 instead of the ordered medication. The facility's policies require medications to be administered as prescribed, within specified time frames, and in accordance with prescriber orders. However, staff failed to follow these protocols, as evidenced by the administration of medications at incorrect times, incorrect dosages, and substitution of medications. These actions directly contributed to the facility's elevated medication error rate, exceeding regulatory standards.