Medication Error Rate Exceeds 5% Due to Administration and Documentation Failures
Penalty
Summary
Licensed staff failed to maintain a medication error rate below 5 percent, as evidenced by three errors out of 26 observed opportunities, resulting in an 11.54% error rate. For one resident, an LPN withheld a scheduled dose of Amlodipine due to a heart rate of 59 bpm without a physician's order to do so and documented the medication as administered on the Medication Administration Record (MAR), despite not giving it at the scheduled time. For another resident, the LPN administered Brimonidine Tartrate Ophthalmic Solution to only one eye when the physician's order specified both eyes, and failed to administer Cholecalciferol (Vitamin D) because it was not available, yet documented it as given on the MAR. The LPN stated that she would typically notify the pharmacy and physician when medication is unavailable and document accordingly, but in these instances, the MAR was inaccurately completed. The errors were confirmed during medication administration reconciliation and through staff interviews, with the LPN acknowledging the discrepancies in documentation and administration. The deficiencies were brought to the attention of facility leadership.