Medication Error Rate Exceeds 5% Due to Incorrect Dosage and Omitted Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.89% based on three errors out of 38 observed opportunities. These errors involved two residents and two medication aides during medication administration. The errors included administering the incorrect dosage of a prescribed medication and omitting required medications during scheduled medication passes. One incident involved a cognitively intact female resident with a history of coronary artery disease, heart failure, depression, and muscle weakness. The medication aide administered 1000 mcg of Vitamin B-12 instead of the prescribed 100 mcg and failed to administer duloxetine 60 mg as ordered. The medication administration record was inaccurately signed to indicate that the medications were given as ordered, and a late administration note was entered, but the correct medications were not provided at the scheduled time. The aide later acknowledged misreading the dosage and missing the duloxetine during the medication pass. Another incident involved a cognitively intact female resident with heart failure and anemia. The medication aide failed to administer the resident's prescribed folic acid 1 mg during the morning medication pass, although the medication administration record was signed as if it had been given. The aide later confirmed the omission. Facility policy requires medications to be administered and documented as ordered by the physician, with verification of the medication and dosage prior to administration, but these procedures were not followed in the cited instances.