Medication Error Rate Exceeds Five Percent Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as two medication errors were identified out of 25 opportunities, resulting in an eight percent error rate. The errors involved a resident with a history of kidney disease, metabolic encephalopathy, and seizures, who had mild cognitive impairment. The resident had active physician orders for Aspirin 81 mg chewable daily for DVT prevention and Mucinex (Guaifenesin) 12-hour 600 mg extended release twice daily for pneumonia. During medication administration, an LPN prepared and administered Aspirin 81 mg enteric coated and Guaifenesin 400 mg extended release, instead of the prescribed forms. The medications were also crushed, despite facility policy and documentation stating that enteric coated and extended release medications should not be crushed. There was no physician order to crush these medications. Interviews with the LPN and the DON confirmed that the medications were crushed and that this was not in accordance with the physician's orders or facility policy.