Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with six errors out of 25 opportunities, resulting in a 24% error rate. Multiple instances were observed where nursing staff did not administer medications according to physician orders. In one case, a nurse prepared and nearly administered an incorrect dose of Risperidone to a resident with dementia, initially placing 3.25 mg in the medication cup instead of the ordered 1.25 mg. The error was only partially corrected after review, and the correct dose was not immediately available. Another incident involved a resident with hypertension who was scheduled to receive Metoprolol Succinate ER 25 mg daily. The nurse withheld the medication due to a low blood pressure reading, despite there being no physician-ordered parameters to hold the medication. The nurse did not notify the physician of the withheld dose, nor did they inform the physician when a medication was unavailable for another resident. Additionally, a resident prescribed Sucralfate 1 gm/10 ml for gastrointestinal issues was nearly given an incorrect volume due to improper measurement technique, which was only corrected after intervention. Further, a resident was administered the wrong dosage of Simethicone due to the unavailability of the prescribed strength, with the nurse giving 125 mg tablets instead of the ordered 80 mg. The nurse was unaware of the dosage discrepancy and had already administered the incorrect dose earlier in the day. These events demonstrate repeated failures to follow medication administration protocols, including verifying correct dosages, ensuring medication availability, and communicating with physicians when deviations from orders occurred.