Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy and regulation. During medication administration observations, two of four nurses did not properly administer two of thirty-two medications to one resident. Specifically, one nurse administered an enteric-coated blood thinner instead of the prescribed chewable form for a resident with heart issues, contrary to the physician's order. The nurse acknowledged not checking the physician order before administering the medication. On a separate occasion, another nurse administered artificial tear eye drops to the same resident for dry eyes, despite the physician's order specifying medicated eye drops for eye irritation. The nurse admitted to misinterpreting the order and not following the physician's instructions. These errors resulted in a medication error rate of 6.25%, exceeding the acceptable threshold and not aligning with the facility's medication administration policy.