Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required by regulation. During a medication pass observation, one of two nurses made two errors out of 33 opportunities, resulting in a medication error rate of 6.06%. Specifically, a nurse did not follow physician orders for a resident by administering Lactase tablets after the resident had already consumed breakfast, instead of before the meal as ordered. Additionally, the nurse administered two sprays of saline nasal solution in each nostril, rather than the prescribed one spray per nostril. These errors were confirmed through observation, interview, and record review. The nurse acknowledged during an interview that the medications were not administered according to the physician's orders, stating that he should have given the Lactase before the meal and only one spray of saline per nostril. The errors directly impacted one resident who had orders for Lactase for lactose intolerance and saline nasal spray for dryness.