Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.9% based on 2 errors out of 29 observed opportunities. One error involved a male resident with coronary artery disease, dementia, GERD, and hypertension, who was ordered to receive Omeprazole 20 mg, two tablets by mouth twice daily. On the observed date, the nurse administered only one 20 mg tablet instead of the prescribed two, resulting in an underdose. The resident's care plan required medications to be administered as ordered and for staff to monitor and document side effects and effectiveness. A second error involved a female resident with heart failure, dementia, GERD, and hypertension, who was ordered to receive Flonase Allergy Relief (fluticasone) nasal spray, two sprays in each nostril twice daily. During medication administration, the nurse administered only one spray instead of the prescribed two. The nurse later acknowledged the mistake, stating she thought she had given two sprays but realized she had not. The facility's policy required medications to be administered and documented as ordered by the physician and in accordance with state regulations.