Medication Error Rate Exceeds 5% Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 2 errors identified out of 29 opportunities, resulting in a 6.9% error rate. In one instance, a registered nurse was unable to locate a resident's prescribed topical diclofenac sodium gel and subsequently used another resident's Voltaren gel to administer the medication. The nurse acknowledged that this was not the correct procedure, as medications should not be shared between residents. Documentation also showed that the nurse did not update the primary care provider or pharmacy about the medication's unavailability as required by facility policy. In another case, a resident with a physician's order for daily lidocaine patches to be applied and removed after 12 hours did not have the previous day's patch removed as ordered. The nurse applied two new patches without first removing the old one, contrary to the physician's instructions. Review of the medication administration record indicated that the removal of the previous patch was documented, but observation confirmed it was still in place, indicating a failure to follow the prescribed medication regimen.