Medication Error Rate Exceeds 5% Due to Incorrect Timing of Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two errors out of 33 observed opportunities, resulting in a 6.06% error rate. Specifically, an LPN prepared and administered two medications—Atorvastatin 20 mg and Loratadine 10 mg—to a resident during the morning medication pass, despite both medications being ordered for administration at bedtime. The LPN acknowledged the error, stating awareness that the medications were scheduled for nighttime and that they were pulled in error. The contracted pharmacist confirmed that while no immediate harm was expected, the efficacy of Atorvastatin could be reduced when given in the morning, and Loratadine could cause daytime drowsiness. The pharmacist also noted the risk of exceeding the maximum daily dose if the medication was administered again at bedtime. Both the DON and the Administrator stated their expectations that medications be administered according to physician orders and facility policy.