Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with three medication errors identified out of 30 observed opportunities, resulting in a 10% error rate. The errors involved three residents: one did not receive a prescribed dose of tiotropium inhalation for COPD, another did not have a lidocaine patch removed after the ordered 12-hour period, and a third did not receive a scheduled dose of entacapone for Parkinson's Disease. These errors were observed during medication administration rounds and confirmed through interviews with nursing staff and review of medical records. For the resident prescribed tiotropium, the medication was neither prepared nor administered during the observed medication pass, and the responsible nurse admitted to forgetting to give the medication, failing to follow the five rights of medication administration. The resident with the lidocaine patch had the previous day's patch still in place well past the 12-hour removal time, as confirmed by both observation and the nurse's statement. The nurse acknowledged that the patch should have been removed according to the physician's order and facility policy, and that this omission constituted a medication error. The resident prescribed entacapone did not receive the medication during the scheduled administration time because it was not available in the medication cart. The nurse responsible did not administer the medication within the required time window and stated that this was a medication error. The Director of Nursing confirmed that these incidents were medication errors and that the involved staff did not follow facility medication administration guidelines or physician orders, as supported by facility policies and procedures reviewed during the survey.