Medication Error Rate Exceeds 5% Due to Omitted Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 30 opportunities, resulting in a 6.67% error rate. Specifically, a resident with chronic respiratory failure, iron-deficiency anemia, and a stage 4 pressure ulcer did not receive prescribed doses of guaifenesin and multivitamin via g-tube because the medications were not available on the medication cart or in the back-up supply. The nurse on duty prepared and administered the resident's other medications but omitted the unavailable medications without notifying the provider or obtaining an order to omit the doses. Documentation on the medication administration record indicated the omission, but there were no corresponding progress notes explaining the situation. During interviews, the nurse acknowledged awareness of the missing medications and stated that she typically would notify the provider but did not do so in this instance. The Director of Nursing confirmed that the nurse should have notified the provider and that the process for unavailable medications involves reordering by the unit manager.