Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors observed during medication administration for two out of six residents. Specifically, an LPN administered an incorrect dose of a nutritional supplement to one resident by providing 8 ounces instead of the prescribed 6 ounces. The LPN was unsure of the correct measurement method and used a plastic cup that held more than the ordered amount. This error was confirmed through observation and review of the resident's Medication Administration Record (MAR), which specified the correct dose. Additionally, the same LPN administered only one puff of Spiriva Respimat Inhalation Aerosol Solution to another resident, despite the order requiring two puffs for COPD management. The LPN acknowledged the error during an interview and confirmed understanding of the correct procedure. Review of the MAR corroborated that the order was for two inhalations. These two errors resulted in a medication error rate of 5.3% (2 errors out of 38 opportunities), exceeding the acceptable threshold.