Medication Error Rate Exceeds Acceptable Threshold Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, resulting in a medication error rate of 7.41%, which exceeds the acceptable threshold of less than 5%. Two medication errors were observed out of 27 opportunities during medication administration. In the first instance, a resident with chronic obstructive pulmonary disease and osteoporosis did not receive their prescribed calcium 600 mg because it was not available in the medication cart. The LPN confirmed the medication was a special order and not in stock, and the DON verified that only calcium with vitamin D3 was available in the facility. In the second instance, another resident with Parkinson's disease and chronic obstructive disease did not receive their ordered budesonide-formoterol fumarate inhalation aerosol, as it was also not available in the medication cart. The LPN confirmed the medication was unavailable, and the DON explained that aerosol medications were not kept in stock and needed to be specially ordered. The facility's medication administration policy requires medications to be administered as ordered by the physician, but this was not followed in these cases.