Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 10 percent, exceeding the acceptable threshold of less than 5 percent, based on three identified errors out of 30 observed opportunities. Two residents were administered Aspirin 81 mg enteric coated tablets without a physician's order specifying this formulation. In both cases, the physician's order required Aspirin 81 mg chewable tablets, but the nurse administered the enteric coated version instead. The nurse confirmed during interviews that the correct chewable form was not available in the medication cart at the time of administration, and the pharmacy consultant verified that the two formulations are not interchangeable. Another incident involved a resident with hepatic encephalopathy who did not receive a scheduled dose of Lactulose, a medication prescribed to be given four times daily. The nurse prepared and administered the resident's other morning medications but omitted the Lactulose, later confirming that it was forgotten. The physician's order for Lactulose was clear, and the facility's policy required medications to be administered within one hour of the scheduled time. The pharmacy consultant noted that missing a dose could affect the intended treatment. In all three cases, the facility's policy and procedure for administering medications required staff to verify the right resident, medication, dosage, time, and method of administration, and to follow prescriber orders. The observed errors demonstrated a failure to adhere to these policies, resulting in the administration of incorrect medication formulations and the omission of a prescribed dose.