Medication Error Rate Exceeds 5% Due to Missed and Improperly Administered Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with three medication errors observed out of 31 opportunities, resulting in a 9% error rate. During a medication pass, an LVN administered MiraLAX oral powder to a newly admitted female resident without the required amount of fluid, and failed to administer both Advair HFA inhalation aerosol and Isosorbide Mononitrate ER oral tablets as ordered. The resident had been admitted the previous night with diagnoses including hypertension, constipation, blood clots, and generalized weakness. Physician orders required these medications to be given at specific times, but the MAR indicated that only the MiraLAX was documented as given, and not according to the prescribed method. The LVN reported that the medications were not available in the pharmacy-provided stock machine and had not arrived with the morning pharmacy delivery. The LVN stated she informed the resident, the DON, and intended to follow up with the physician and pharmacy. The DON confirmed that late admissions often resulted in delayed medication delivery from the pharmacy and that staff were expected to notify both the physician and DON if medications were unavailable. The Administrator was unaware of any issues with medication delivery for late admissions and believed the pharmacy could be contacted at any time. Facility policy required medications to be administered according to established schedules and physician orders.