Medication Error Rate Exceeds Acceptable Threshold Due to Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 7.41% error rate identified during a survey. Specifically, LVN C did not administer medications as ordered for two residents. For one resident with an active order for 800 mcg of folic acid daily via G tube for anemia, LVN C only administered one 400 mcg tablet, citing the absence of 0.8 mg tablets in the medication cart. For another resident with an active order for 12.5 mg of hydrochlorothiazide daily for hypertension and edema, LVN C withheld the medication without a physician's order to do so, based on her assessment of the resident's blood pressure and the presence of hold parameters on other antihypertensive medications. Interviews with facility staff confirmed that the orders for both medications were clear and did not include parameters for withholding doses. The facility's policy required medications to be administered as prescribed and for staff to verify the correct medication, dose, and administration method. The failures were observed directly by the surveyor during medication passes and were acknowledged by both LVN C and supervisory staff during interviews.