Medication Error Rate Exceeds 5% Due to Incorrect Dosages
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.66% during the observed medication administration task. For one resident with a diagnosis including vitamin D deficiency, an LPN administered 2000 IU of cholecalciferol instead of the prescribed 1000 IU. This error was identified through observation and review of the Medication Administration Record (MAR), which confirmed the incorrect dosage was given. Another resident with chronic pain syndrome, back spasm, and neuropathy received 40 mg of morphine sulfate oral solution on multiple occasions, despite the MAR indicating a prescribed dose of 20 mg. Both an RN and another nurse administered the higher dose, and the Controlled Substance Proof-Of-Use Record corroborated the administration of the incorrect amount. The facility's medication administration policy requires adherence to the six rights of medication administration, including the right dosage and review of the MAR, which was not followed in these instances.