Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent, as required by policy, resulting in a medication error rate of 16.67 percent during the observed medication pass. During the observation, an LPN was seen preparing and administering medications to a resident who had a blood sugar of 216 and was scheduled to go to dialysis. The LPN initially drew up the incorrect dose of 70/30 insulin (5 units instead of the ordered 3 units) but corrected the dose before administration after the error was noticed. Additionally, the LPN administered only one capsule each of Vitamin D and Docusate, despite orders for two capsules of each, and omitted administration of Pantoprazole Sodium and Thiamine, both of which were ordered for the resident at that time. Upon interview, the LPN acknowledged the errors, attributing them to being flustered by the resident's presence at the medication cart and the urgency of the resident needing to leave for dialysis. The LPN confirmed that only one capsule each of Vitamin D and Docusate was given, and that Pantoprazole and Thiamine were not administered as ordered. The surveyor confirmed these omissions and incorrect dosages through observation and review of the medication administration records and physician orders.