Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 28 opportunities during a medication pass, resulting in a 10.71% error rate. Two out of three nurses observed made errors that affected two residents. Specifically, one nurse administered the incorrect probiotic formula to a resident, giving Acidophilus instead of the prescribed Saccharomyces boulardii, as per the physician's order. The nurse stated that Acidophilus was typically used as house stock and acknowledged not following the specific physician's order. Another nurse administered the incorrect formula of Calcium and provided a Multivitamin with Minerals instead of the prescribed PreserVision AREDS Tablet to a different resident. The nurse confirmed these errors during an interview. The Director of Nursing stated that the expectation is for nurses to administer medications according to physician orders. These actions resulted in a medication error rate exceeding the regulatory threshold.