Medication Error Rate Exceeds Regulatory Threshold Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in a 6.45% error rate during the survey period. Two medication errors were observed among 31 opportunities. In the first instance, an LPN administered Symbicort Inhalation Aerosol to a resident with a diagnosis of Toxic Encephalopathy and a BIMS score indicating cognitive intactness, but did not instruct the resident to rinse their mouth after administration. Both the LPN and the DON confirmed that mouth rinsing is necessary after using an inhaled corticosteroid to prevent oral thrush, and the medication guide also specifies this step. In the second instance, another LPN prepared an incorrect dosage of Thiamine for a resident admitted with a humerus fracture. The LPN placed a 100 mg Thiamine tablet in the medication cup, despite the physician's order specifying a 50 mg dose. The LPN later confirmed the error upon reviewing the medication label and removed the incorrect tablet. The DON acknowledged that medications must be administered according to physician orders and that incorrect dosing could result in negative outcomes. These observed actions directly contributed to the facility's medication error rate exceeding the regulatory threshold.