Medication Error Rate Exceeds 5% Due to Incorrect Administration and Unauthorized Substitution
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by 3 errors out of 27 observed opportunities, resulting in an 11.11% error rate. One resident, a female with diagnoses including bipolar disorder, diabetes mellitus type 2, myopia, and an intraocular lens, was administered Primidone in the morning instead of at hour of sleep as ordered by her physician. Additionally, she was given Artificial Tears instead of her prescribed Pataday eye drops, and the dosage administered was not consistent with the physician's order. The nurse responsible for the medication pass stated she was nervous due to being observed and using paper MARs during a Wi-Fi outage, which contributed to the errors. She also reported that she had not been supervised by the DON or administration during medication administration and had only trained with other charge nurses before working independently. The nurse further explained that she substituted Artificial Tears for Pataday based on information from the Central Supply Assistant, without obtaining a physician's order for the substitution. The Central Supply Assistant confirmed that Artificial Tears were kept in stock and Pataday required a special order, but no authorization was obtained for the substitution. The facility's medication administration policy requires medications to be given as prescribed, but this was not followed in these instances, resulting in the resident not receiving medications as ordered.