Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 8% based on 2 errors out of 25 opportunities. During a medication pass observation, a medication aide (MA) administered medications to a female resident with chronic embolism, chronic kidney disease, and muscle weakness, who had moderately impaired cognition. The MA did not instruct the resident to chew the prescribed chewable aspirin and failed to ensure the buprenorphine was administered sublingually as ordered. These actions were confirmed through observation, interview, and record review. The MA acknowledged misreading the administration instructions for both the chewable aspirin and the sublingual buprenorphine, stating that medications must be given as ordered by the physician. The Director of Nursing (DON) confirmed that staff are expected to follow the five rights of medication administration and consult with nursing leadership or the physician if there are any questions about medication orders. Facility policy also requires staff to perform three checks comparing the physician's order, pharmacy label, and medication administration record.