Medication Error Rate Exceeds 5% Due to Improper Administration and Omission
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 5.41% error rate during a medication pass observation. Specifically, an LPN administered Sevelamer Carbonate, a phosphate binder, to a resident after the resident had already eaten breakfast, despite physician orders specifying the medication should be given before meals. Additionally, the same resident was not administered Ondansetron HCl, which was ordered to be given on specific days related to dialysis, during the observed medication pass. The LPN later confirmed that Sevelamer Carbonate was given after the meal and that Ondansetron was administered only after the medication pass observation was completed. The LPN did not notify the DON or the surveyor prior to administering the missed medication. These actions resulted in two medication errors out of 37 opportunities, exceeding the acceptable medication error rate threshold.