Medication Error Rate Exceeds Acceptable Threshold Due to Improper Crushing of ER Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 30 observed opportunities, resulting in an error rate of 6.67%. In one instance, a resident with a diagnosis of hypertension was prescribed Metoprolol Succinate Extended Release (ER) 25 mg daily. During medication administration, a Certified Medication Aide (CMA) crushed the Metoprolol ER tablet along with other medications and administered the mixture to the resident. The pharmacist later confirmed that ER tablets should not be crushed, as this could result in the resident receiving too much medication at once. In another case, a CMA prepared and crushed a Potassium Chloride ER tablet for a resident, mixing it with other medications. The surveyor intervened before administration, instructing the CMA not to give the crushed medication, as Potassium Chloride ER should not be crushed. The facility's medication administration policy did not provide guidance on which medications should not be crushed, such as extended-release formulations. These actions led to the facility exceeding the acceptable medication error rate.