Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required. During observation of medication administration, a total of 26 medication opportunities were reviewed, and two errors were identified, resulting in a 7.69% error rate. Specifically, a resident with diagnoses including diabetes, hypertension, and depression was observed during morning medication administration. The LPN on duty administered 16 different medications, totaling 18 pills, but omitted two prescribed medications: Lisinopril 20 mg and Claritin 10 mg. The omission was confirmed during an interview with the LPN, who acknowledged not administering the two medications as ordered by the physician. Review of the facility's medication administration policy indicated that medications must be given in accordance with physician orders. This incident was documented as part of an investigation under multiple complaint numbers, and the facility census at the time was 59.