Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Dosage and Timing
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent, as evidenced by two medication errors out of 30 observed opportunities, resulting in a 6 percent error rate. In the first instance, a licensed vocational nurse administered only 10 mg of Baclofen to a resident with chronic pain syndrome, despite a physician order for 15 mg three times daily. The nurse acknowledged the error, confirming that only one tablet was given instead of the required one and a half tablets, and the facility's policy required confirmation of medication orders prior to administration. In the second instance, another resident with type 2 diabetes was administered Metformin 500 mg without breakfast, contrary to the physician's order specifying administration with breakfast and dinner. The nurse confirmed that the medication was not given within the appropriate time frame relative to the meal, and the facility's policy required medications with specific administration instructions to be given according to manufacturer recommendations. The pharmacist also confirmed that Metformin should be administered with food to prevent gastrointestinal discomfort.