Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 7.4%, which exceeds the acceptable threshold of 5%. Specifically, two medication errors were identified out of 27 medication opportunities during observation of medication administration. One resident with a history of hypertension and transient cerebral ischemic attack was ordered to receive Verapamil HCL Extended Release 240 mg, but instead was given Verapamil HCL 120 mg two tablets. Another resident with type two diabetes and hypertension was ordered Metformin HCL 1,000 mg twice daily, but only received Metformin HCL 500 mg once during the observed medication pass. The errors were confirmed through medical record review, direct observation, and staff interview. The nurse responsible for medication administration acknowledged the errors, stating she was unaware of the new Verapamil 240 mg ER order and confirmed the incorrect dosage of Metformin was given. Facility policy required medications to be administered as ordered, ensuring all rights of medication administration were followed, but these protocols were not adhered to in these instances.