Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a medication pass, resulting in a calculated error rate of 9.68% based on 31 observed opportunities and three identified errors. During the medication administration, an LPN gave a resident Aspirin 81 mg without a physician order, did not administer the prescribed Multivitamin 18 mg with iron and folic acid, and administered Vistaril (hydroxyzine pamoate) 25 mg at the incorrect time, contrary to the physician's specific instructions. The LPN acknowledged mistaking the Aspirin bottle for the Multivitamin and confirmed the errors in medication administration and timing. The resident involved had diagnoses including hemiplegia, major depressive disorder, and generalized anxiety disorder, and was under a care plan that included monitoring for complications related to blood thinning medications. The errors were confirmed by the LPN, the Assistant Director of Nursing, the Pharmacist Consultant, and the Nurse Practitioner, all of whom verified that the medications were not administered as ordered. Facility policy required staff to follow the eight medication rights, including administering the right drug at the right time, which was not adhered to in this instance.