Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5%, resulting in a calculated error rate of 6.45% during observed medication administration. For one resident, a licensed nurse administered only two lidocaine 5% patches for lower back pain, despite the physician's order specifying three patches. Review of the Medication Administration Record (MAR) confirmed the discrepancy, and the nurse acknowledged the error during an interview. The facility's policy required medications to be administered according to physician orders and for staff to verify the correct dosage before administration. In a separate incident, another licensed nurse administered finasteride 5 mg to a different resident without wearing gloves, contrary to the physician's order and the medication's safety data sheet, which indicated the need for gloves due to potential reproductive toxicity. The nurse admitted to being unaware of the special handling requirements and did not use gloves during administration. The Director of Nursing confirmed that the medication was not administered per the physician's orders. Both incidents were observed and documented during the survey, contributing to the facility's medication error rate exceeding the regulatory threshold.