Medication Error Rate Exceeds 5% Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5% by not administering prescribed medications as ordered to three residents during observed medication administration. Specifically, Miralax 17 gm was not given to two residents as ordered, and Omeprazole 20 mg was not administered to another resident. Review of physician orders confirmed that these medications were prescribed for constipation and for administration via PEG tube, respectively. Staff interviews revealed that the medications were out of stock and unavailable at the time of administration. A total of 31 medication administration opportunities were observed, with three errors identified, resulting in a medication error rate of 9.68%. The Director of Nursing confirmed the error rate exceeded the acceptable threshold.