Medication Error Rate Exceeds 5% Due to Incorrect Eye Drop Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by a 5.56% error rate resulting from 2 errors out of 36 observed opportunities. Specifically, a medication aide (MA) did not administer Artificial Tears as ordered and incorrectly administered Moxifloxacin Ophthalmic Solution in both eyes instead of only the left eye for a resident. The errors were observed during a medication pass, and the MA later confirmed she misread the order and omitted the Artificial Tears due to being distracted while preparing medications. The resident involved was an older female with dementia and candidiasis of the skin and nail, who had physician orders for both Artificial Tears and Moxifloxacin eye drops. The resident's care plan and medication administration record reflected these orders, but the observed administration did not follow them. Interviews with the MA, DON, ADON, and Administrator confirmed the errors and acknowledged the importance of adhering to physician orders during medication administration. The facility's policy required strict adherence to the six rights of medication administration, which was not followed in this instance.