Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications according to practitioner’s orders and manufacturer’s recommendations, resulting in a medication error rate of 12% based on 25 observed medication administration opportunities. Specifically, two residents received omeprazole after consuming breakfast, despite clear instructions on the medication card to administer the drug 60 minutes prior to meals. Both the medication aide and the Director of Nursing confirmed that the medication was not given at the correct time, as required. Additionally, one resident did not have their mouth rinsed after receiving Trelegy Ellipta, an inhaled medication, contrary to the instructions to rinse the mouth after use. The medication aide acknowledged this omission during the interview, and the Director of Nursing confirmed that the mouth should have been rinsed. The facility’s own Medication Administration policy also requires mouth rinsing after inhaler use and administration of medications within the specified time frame.