Medication Error Rate Exceeds Regulatory Threshold Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with a calculated error rate of 7.14 percent based on 28 medication opportunities and two errors. During a medication administration pass, an LPN prepared and administered Brimonidine Tartrate-Timolol Ophthalmic Solution to a resident by instilling one drop in each eye, despite the physician's order specifying administration only to the right eye for glaucoma. The LPN confirmed the medication was given in both eyes, contrary to the order. Additionally, the same resident was administered a lactase enzyme supplement without any food present, although the physician's order and medication instructions specified that the supplement should be given with meals to aid in lactose intolerance. Interviews with staff and the resident confirmed that the resident's family had brought breakfast earlier that morning, but the supplement was not administered with the meal as directed. These actions resulted in a medication error rate above the regulatory threshold.