Medication Error Rate Exceeds Acceptable Threshold Due to Unavailable Medications
Penalty
No penalty information released
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Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by two medication errors out of 25 observed medication administration opportunities, resulting in an 8 percent error rate. Specifically, one resident with diabetes and obesity did not receive their scheduled dose of Jardiance because the medication was not available, despite a physician's order for daily administration. Another resident with muscle weakness did not receive their prescribed Ingrezza for a movement disorder, also due to the medication not being available at the time of administration. In both cases, staff reported that the medications had been ordered from the pharmacy but had not yet arrived, leading to missed doses.