Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as two medication errors were observed out of 30 opportunities during medication administration, resulting in a 6.67% error rate. During observation, a resident was scheduled to receive Metoprolol 25 mg and Thiamine 100 mg at 9:00 AM, but neither medication was observed being prepared or administered at the designated time. Upon questioning, the administering RN admitted to documenting the administration of Thiamine when it had not been given and subsequently provided the medication after the discrepancy was identified. The RN also stated that Metoprolol had been administered but could not provide evidence of its preparation or administration during the observation period.