Medication Error Rate Exceeds 5% Due to Missed Dose and Improper Inhaler Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 2 medication errors out of 31 observed medication administration opportunities, resulting in a 6.45% error rate. In one instance, a resident with glaucoma did not receive a prescribed dose of Dorzolamide HCL-Timolol Maleate Ophthalmic Solution because the medication was not available on the medication cart. The nurse responsible was unable to locate the medication and did not provide a reason for its absence, stating only that he would contact the pharmacy to reorder it. In another case, a resident with chronic obstructive pulmonary disease (COPD) was administered Budesonide-Formoterol Fumarate Inhalation Aerosol incorrectly. The nurse administered two puffs of the inhaler without shaking it between doses, contrary to the manufacturer's instructions, which require the inhaler to be shaken for 5 seconds before each puff. The nurse acknowledged forgetting this step during administration. Both incidents were observed during medication passes and confirmed through staff interviews and record reviews.