Medication Error Rate Exceeds Acceptable Threshold Due to Incomplete Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to properly administer medications to a resident with multiple diagnoses, including diabetes mellitus, rheumatoid arthritis, and dementia. The LVN crushed and prepared each of the resident's prescribed medications in separate cups with applesauce, but did not ensure that the full doses were administered. After the medication pass, it was observed and confirmed by the LVN that residual medication remained in the cups, resulting in incomplete dosing for the resident. This incident led to seven medication errors out of 26 opportunities, resulting in a medication error rate of 26.92%, which is significantly above the acceptable threshold of less than 5%. The resident was dependent on staff for all activities of daily living and had limited ability to communicate or understand others, further emphasizing the need for accurate medication administration. The facility's policy required medications to be administered safely, timely, and as prescribed, which was not followed in this instance.