Medication Error Rate Exceeds Five Percent Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less during observed medication administration, resulting in an error rate of 7.69%. During medication pass observations for six residents, two errors were identified out of 26 observations. One resident with multiple diagnoses, including severe cognitive impairment, was administered Metoprolol Succinate ER 100 mg and Potassium CL ER 20 mEq, both labeled 'do not crush,' in crushed form along with Eliquis. These medications were crushed and given in pudding by an LPN, despite clear labeling and facility policy instructions. The LPN confirmed the medications were crushed and administered, and a pharmacist later verified that these medications should not be crushed. The facility's medication administration policy requires staff to adhere to the 10 rights of medication administration, including verifying the correct form of the drug. The facility's policy on medication-related errors also outlines steps for notification and monitoring if a medication error occurs. The deficiency was identified through direct observation, record review, and staff interviews.