Medication Error Rate Exceeds Five Percent Due to Administration and Documentation Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a calculated error rate of 5.41 percent during the survey period. One incident involved a staff member delaying the administration of insulin to a resident until after the resident had finished breakfast, despite a physician's order specifying that insulin should be given before meals. In another case, a staff member administered acetaminophen to a resident during breakfast but incorrectly documented it as pantoprazole in the medication administration record (MAR), and did not administer the pantoprazole as scheduled before the resident ate, contrary to the physician's order for administration at 7:00 a.m. These actions resulted in medication errors for two residents out of a sample of twenty-five.