Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with two medication errors identified out of 30 observed opportunities, resulting in a 6.67% error rate. The first error involved a resident with hypertension, osteoarthritis, and encephalopathy, who was ordered to receive carvedilol with food. During medication administration, the nurse gave the resident carvedilol without offering food, contrary to the prescriber's order. The nurse later confirmed that the medication was not administered with food, and the DON acknowledged the importance of following medication orders to ensure effectiveness and prevent complications. The second error involved a resident with end stage renal disease, anemia, and syncope, who was ordered to receive sevelamer with meals. During observation, the nurse administered sevelamer and other medications to the resident without a meal present at the bedside. The resident confirmed that medications were given after breakfast, but not with food. A registered nurse stated that medications ordered to be given with meals should be administered accordingly to avoid stomach upset or reduced effectiveness, and that food should be offered when administering sevelamer after breakfast is served. A review of the facility's medication administration policy indicated that drugs must be administered in accordance with the written orders of the attending physician and that all medications should be given following the scheduled administration times unless otherwise specified. The observed failures to administer medications as ordered, specifically regarding the requirement to give certain medications with food, directly contributed to the facility's medication error rate exceeding the acceptable threshold.