Medication Error Rate Exceeds 5% Due to Missed Dose and Lack of Pre-Administration Assessment
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a calculated rate of 6.45% based on 2 errors out of 31 observed opportunities. The first error involved a female resident with a history of diverticulitis, mood disorder, anxiety, and hypertension, who did not receive her physician-ordered hydralazine as it was not available during the scheduled medication pass. The medication aide was unaware of the unavailability until the time of administration and did not notify the charge nurse, resulting in the resident missing a dose for her anxiety and blood pressure management. The second error involved a male resident with dementia, epilepsy, polyneuropathy, and osteoporosis, who was prescribed Metoprolol Tartrate with specific parameters to hold the medication if his blood pressure or heart rate fell below certain thresholds. The medication aide prepared and was about to administer the medication without checking the resident's blood pressure, as there was no designated area in the medication administration record for documenting this assessment. The aide assumed the check was unnecessary and only measured the blood pressure after being prompted by the surveyor. Interviews with staff revealed a lack of communication and understanding regarding medication availability and the need for pre-administration assessments. The charge nurse was not informed about the missing hydralazine, and the admitting nurse did not enter blood pressure parameters into the electronic system for the second resident. Facility policies required timely medication availability and pre-administration assessments, but these were not followed, leading to the observed deficiencies.