Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with three errors observed out of twenty-nine opportunities, resulting in a 10.34% error rate. For one resident with Alzheimer's Disease, chronic kidney disease, and hypertension, a physician order specified Aspirin 81 mg delayed release, not to be crushed. However, an LPN crushed and administered a chewable Aspirin 81 mg tablet instead, contrary to the order. Another resident with a history of femur fracture, diabetes, epilepsy, and failure to thrive did not receive a scheduled dose of Phenobarbital 32.4 mg in the morning because the medication was not available in the narcotic drawer, and the nurse confirmed it could not be administered as ordered. A third resident, diagnosed with malignant neoplasm, secondary bone neoplasm, fibromyalgia, and chronic kidney disease, was ordered to receive Aspirin 81 mg by mouth in the morning. During medication administration, an RN provided a chewable Aspirin 81 mg tablet, which the resident swallowed, and later confirmed this was not in accordance with the physician's order. In all cases, facility policy required medications to be administered as per written physician orders, but these were not followed, leading to the cited deficiency.