Medication Pass Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication pass error rate of less than 5%, resulting in a 6.9% error rate during the survey. This deficiency was identified through observation, interview, and record review, where two residents out of five applicable residents experienced medication administration errors out of 29 opportunities. The facility's policies required adherence to the Five Rights of Medication Administration and safe medication practices, but these were not followed in the observed incidents. One resident with a history of cerebral infarction, hemiplegia, dysphagia, and failure to thrive was ordered to receive Ferrous Sulfate Oral Solution via G-Tube, but was instead administered a crushed Ferrous Sulfate tablet. The nurse acknowledged the error during an interview. Another resident with diagnoses including normal pressure hydrocephalus, Parkinson's Disease, heart disease, and dementia was ordered to receive two 500 mg Fish Oil capsules (total 1000 mg) but was given two 1000 mg capsules (total 2000 mg). The nurse also confirmed the error during an interview. These actions directly led to the facility exceeding the acceptable medication error rate.