Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of eight percent based on three errors out of thirty-five opportunities. These errors involved two residents and were identified through observation, interview, and record review. The first incident involved a resident with dementia, protein-calorie malnutrition, and constipation, who was dependent on staff for activities of daily living. The resident was administered Sennoside 8.6 mg instead of the ordered Sennoside 8.6 mg with Docusate 50 mg, and Multivitamins with minerals instead of the prescribed Multiple Vitamins without minerals. The nurse administering the medication stated that the correct medications were not available in the facility and that substitutions were made based on what was in stock, despite the differences in formulation. The medication supply room was found to have the correct Multiple Vitamins available, but the Sennoside with Docusate was on back order, and staff had been instructed to purchase it from an outside source. The second incident involved a resident with dementia who required assistance with activities of daily living. The medication aide applied a new Rivastigmine transdermal patch before removing the old one, contrary to the physician's order and facility policy, which required the old patch to be removed prior to applying a new one. The aide stated that she believed placing the new patch first would prevent contamination, and did not perceive a risk in having two patches on simultaneously if the old one was removed immediately after. The Director of Nursing confirmed that the correct procedure was to remove the old patch before applying the new one to avoid multiple patches being present at the same time. Facility policy reviews indicated that staff were required to confirm medication orders and follow specific procedures for oral and transdermal medication administration, including removing old patches before applying new ones. The errors observed were due to staff not following these established protocols, either by substituting medications without proper verification or by not adhering to the correct sequence for patch application.