Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 28 opportunities, resulting in a 7.14% error rate. During a medication pass, an LPN administered the incorrect dose of famotidine to a resident with diagnoses including atrial fibrillation, heart failure, bradycardia, and GERD. The LPN gave 10 mg of famotidine instead of the ordered 20 mg. Additionally, the LPN withheld the resident's metoprolol based on a pulse of 60, despite the physician's order specifying to hold the medication only if the pulse was less than 60 or systolic blood pressure was less than 100. Upon review, the LPN acknowledged the errors when prompted by the surveyor, confirming that the correct famotidine dose should have been two 10 mg tablets and that metoprolol should not have been withheld. These errors were discussed with facility leadership, including the Administrator and Director of Nursing, during the survey process. No further information was provided to the survey team prior to the exit conference.