Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 28 observed opportunities, resulting in a 10.7% error rate. During a medication administration observation, a registered nurse administered incorrect doses of Sertraline, Levothyroxine, and Calcium + Vitamin D3 to a resident. The resident's physician orders and medication administration records showed discrepancies, including the administration of multiple doses of Levothyroxine that exceeded the prescribed amount over several days. Laboratory results indicated an abnormal thyroid stimulating hormone (TSH) level for the resident during this period. The nurse involved acknowledged the errors during an interview, stating she believed she had all the correct medications but made mistakes. The facility's policy requires a triple check of the five rights of medication administration at three separate steps, but this process was not effectively followed. The Director of Nursing confirmed that all medications are expected to be administered as ordered and that any errors or omissions must be reported to the physician and the resident's family.