Medication Error Rate Exceeds Acceptable Threshold
Penalty
No penalty information released
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Summary
The facility failed to maintain a medication error rate below five percent, as required, during medication administration for two of three residents observed. One resident was administered a total of 30 mg of Citalopram (Celexa) by a licensed nurse, despite the physician's order specifying only 20 mg daily for Generalized Anxiety Disorder. In another instance, the same nurse crushed and prepared to administer Clopidogrel 75 mg and Senna Plus Stool Softener tablets to a different resident, even though the physician's orders explicitly stated that these medications should not be crushed. Both errors were confirmed by the nurse at the time of observation. The facility's medication error rate was calculated at 11.54%.