Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 3 errors out of 25 observed opportunities, resulting in a 12% error rate. In one instance, a medication aide administered pantoprazole and ondansetron to a resident while the resident was eating breakfast, despite orders specifying that these medications should be given prior to eating. The pantoprazole was also administered in a 20 mg dose instead of the ordered 40 mg dose. The medication aide confirmed during an interview that the medications were not given according to the prescribed timing. In another case, a resident with an order for aspirin 81 mg enteric coated tablet to be taken with food and not crushed was instead given an 81 mg chewable aspirin tablet. The medication aide acknowledged the error, confirming that the wrong formulation of aspirin was administered. Facility policy requires medications to be administered as ordered by the physician and in accordance with professional standards, which was not followed in these instances.