Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as two out of 31 observed medication administrations were performed incorrectly, resulting in an error rate of 6.45%. During a medication pass, a licensed nurse administered Benztropine mesylate to a resident with Parkinson's disease. The physician's order specified Benztropine mesylate 1 mg by mouth once daily, but the pharmacy dispensed a 20 mg tablet, and the order itself was unclear. The nurse did not clarify the order with the physician prior to administration, and both the nurse and the Director of Nursing acknowledged that clarification should have occurred. In a separate incident, the same nurse administered Olanzapine 20 mg to another resident with schizophrenia in the morning, despite the physician's order specifying 10 mg in the morning and 20 mg at bedtime. The pharmacy had dispensed 20 mg tablets for both morning and bedtime doses, and the medication was not administered according to the physician's order. The facility's policy required medications to be administered in accordance with prescriber orders and for the nurse to verify the correct dosage before administration, which was not followed in these cases.