Medication Pass Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication pass error rate below five percent, as required, resulting in a 7.6% error rate during the survey. Specifically, two residents received incorrect medications during observed medication administration passes. One resident, with a history of Multiple Sclerosis and osteoporosis, was ordered to receive Calcium 1200 mg daily but was instead given Calcium + Vitamin D 600 mg/10 mcg, as this was the medication available in the cart. The nurse documented administration of the ordered medication despite giving a different product. Another resident, with diagnoses including metabolic encephalopathy and a colostomy, was ordered Senna-S (Sennosides-Docusate Sodium) 8.6 mg/50 mg for constipation but was administered Senokot 8.6 mg instead. The nurse again documented administration of the ordered medication, though the correct product was not given, citing unavailability of the prescribed medication. The Director of Nursing confirmed that only the medications prescribed by the provider should have been administered and that the nurse should have obtained the correct medications if unavailable.