Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Form and Dosage Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in a documented error rate of 12% during observed medication administration. Specifically, three out of twenty-five medications administered to two out of five residents were not given as ordered. For one resident, a registered nurse administered Docusate Sodium in tablet form instead of the prescribed capsule form and provided only one Magnesium Oxide 400 mg tablet instead of the ordered two tablets. The nurse acknowledged that the correct form of Docusate Sodium was not available and did not notify the facility or provider, as required by protocol, and also failed to administer the correct dose of Magnesium Oxide. For another resident, a registered nurse prepared and was ready to administer an enteric coated Aspirin 81 mg tablet instead of the prescribed chewable form. Both nurses involved stated they were aware of the need to check the five rights of medication administration and to follow physician orders, but did not do so in these instances. Facility leadership confirmed that staff are expected to verify all medication rights and follow orders precisely, and acknowledged the errors in medication form and dosage for the residents involved.