Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 31 observed opportunities, resulting in a 6.45% error rate. In the first instance, a resident with gastroesophageal reflux disease was prescribed metoclopramide 5 mg to be administered by mouth before meals. During a medication pass, the medication aide gave the medication while the resident was already eating breakfast, contrary to the physician's order specifying administration before meals. The aide acknowledged not reading the medication card directions closely enough prior to administration. In the second instance, a resident with depression was prescribed escitalopram 20 mg by mouth once daily. During medication administration, the aide prepared and administered only 5 mg of escitalopram instead of the ordered 20 mg. Upon review, the aide realized the error was due to not carefully reading the directions on the medication cards, as there were two cards for different dosages. Both errors were confirmed through staff interviews and direct observation.