Medication Error Rate Exceeds 5% Due to Administration and Delivery Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 6.45%. During medication administration, one licensed nurse did not follow physician orders for a resident prescribed metformin for diabetes mellitus. The nurse administered the metformin tablet at 9:22 AM, while the resident had eaten breakfast at 8:00 AM, contrary to the order specifying the medication should be taken with meals. The nurse confirmed the medication was not given as directed with the meal. Additionally, another resident did not receive a prescribed calcium citrate supplement on time following admission because the medication had not yet been delivered by the pharmacy. The nurse stated that all medication orders are sent to the pharmacy upon admission and are usually delivered the same day, but in this instance, the supplement was not available for administration. These events were observed and verified through interviews and medical record reviews.