Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy and regulation. During observed medication passes, staff administered 5 out of 28 medications incorrectly for two residents. For one resident, a pain medication patch was applied to the left hip instead of the right shoulder as ordered by the physician. The nurse involved acknowledged not clarifying the order before administering the medication to a different site than prescribed. For another resident, multiple errors were observed: a chewable form of a medication was given instead of the prescribed enteric-coated form, a blood pressure medication was administered at 25 mg instead of the ordered 75 mg, and an antidepressant was given at 30 mg instead of the prescribed 60 mg. Additionally, a pain medication gel was not applied as required, despite being documented as administered. The DON confirmed that staff are expected to follow the seven rights of medication administration and adhere to physician orders.