Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, resulting in an observed error rate of 11% during the survey. For one resident with asthma, the nurse administered only one puff each of Budesonide-Formoterol Fumarate and Spiriva Respimat inhalers, despite physician orders specifying two puffs of each medication. The nurse also documented in the Medication Administration Record (MAR) that two puffs of each medication were given, which did not match the observed administration. The nurse acknowledged the discrepancy and recognized that the medications were not administered as ordered. In a separate incident, another resident with dysphagia and gastro-esophageal reflux disease was ordered to receive two capsules of Omeprazole DR 20 mg daily. However, the nurse administered only one capsule and documented in the MAR that two capsules were given. The nurse later confirmed that only one capsule was administered and that this did not follow the physician's order. These actions were inconsistent with the facility's medication administration policy, which requires verification and administration of medications as prescribed.