Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Availability Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with five errors identified out of 28 opportunities, resulting in a 17.8% error rate. For one resident with multiple complex diagnoses, including bipolar disorder, hypertension, and a history of esophageal surgery, a medication technician crushed an extended-release Metoprolol tablet, which should not be crushed, and omitted two prescribed medications, Sertraline and Spironolactone, during a medication pass. The technician had signed off on the administration of all medications, but only 12 out of 14 pills were actually given. The resident confirmed that receiving the wrong medication was not uncommon, especially during night shifts, and that he preferred his medications crushed due to swallowing difficulties. Another resident with a history of cerebral infarction, heart failure, and hypertension did not receive the full prescribed dose of Amlodipine and missed several doses of Metoprolol due to the medication being unavailable for an extended period. The LPN administering the medication provided only one Amlodipine tablet instead of two and reported that Metoprolol had been out of stock since a specific date, with unsuccessful attempts to obtain it from the pharmacy and contingency box. The nurse practitioner was notified of the omission, and additional blood pressure monitoring was ordered, but no harm was noted from the missed doses at the time of review. Facility policy requires medications to be administered as prescribed and for staff to document administration on the medication administration record (MAR) after giving the medication. In both cases, staff failed to follow these procedures, either by not administering all prescribed medications, administering them incorrectly, or failing to ensure medication availability, leading to a medication error rate significantly above the acceptable threshold.