Medication Error Rate Exceeds 5% Due to Incorrect Dosage and Incomplete Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors observed out of 26 opportunities, resulting in a 7.69% error rate. For one resident with hypertension and hyperlipidemia, a nurse administered an incorrect dose of atorvastatin calcium, giving only 10 mg instead of the prescribed 20 mg. The nurse acknowledged the error, stating that the dose had recently been increased and she should have administered two tablets to meet the new order. The Director of Nursing confirmed that the medication was not administered according to the physician's order. In another instance, a nurse administered a chewable aspirin tablet to a resident with hyperlipidemia and atrial fibrillation without verifying the dosage, as the physician's order did not specify the required dosage. The nurse admitted that all medication orders should include a dosage and that the aspirin should not have been given without clarification. The Director of Nursing also confirmed that the order was incomplete, lacking the necessary dosage information.