Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation. During observation of medication administration, two errors were identified out of twenty-seven opportunities, resulting in a 7.41% error rate. In one instance, a certified medication aide (CMA) administered carbidopa/levodopa to a resident at 7:55 a.m., despite the medication being ordered for 6:30 a.m. The CMA indicated that the night shift typically administered this medication, but on this occasion, it was delayed and given by the day shift. The medication was ordered to be given three times daily. In another instance, a different CMA administered an incorrect dose of Guaifenesin/DM SF to a resident. The ordered dose was 10 mL, but only approximately 8 mL was measured and given, despite the CMA verifying the amount and stating it was correct. The facility's medication administration policy requires medications to be given at the correct time and dose, and defines such failures as medication errors. The Director of Nursing acknowledged the medication error rate during the survey.