Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 4 errors out of 32 observed opportunities, resulting in a 12.5% error rate. Three nurses were observed making medication administration errors involving three residents. The errors included administering incorrect dosages and failing to follow physician orders regarding medication parameters and administration. One resident with a history of stroke and cognitive intactness was given an incorrect dose of vitamin B6 (50 mg instead of the ordered 100 mg) and did not receive a scheduled dose of xarelto, a blood thinner. The nurse responsible was unaware of the missed xarelto dose and did not realize the vitamin B6 tablets in the cart required two tablets to meet the prescribed dose. Another resident with severe cognitive impairment and hypertension received metoprolol without the nurse first checking vital signs, despite physician orders to hold the medication if blood pressure or pulse were below specified thresholds. The nurse admitted to not obtaining the required vital signs prior to administration. A third resident with moderate cognitive impairment and a history of intestinal obstruction was administered an insufficient dose of polyethylene glycol, as the Assistant Director of Nursing misread the measurement indicator on the medication cap. The ADON later acknowledged the error after reviewing the bottle. In all cases, the Director of Nursing confirmed that medications should be administered exactly as ordered, including correct dosages and adherence to any specified parameters.