Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 11% as three errors were identified out of 27 opportunities during medication administration. For one resident with chronic kidney disease and atrial fibrillation, a LPN administered oxybutynin after the order for the medication had expired, as verified by both observation and staff interview. The resident had intact cognition at the time of the incident. Another resident with a history of stroke, autistic disorder, and peripheral vascular disorder received Vitamin B6 without a documented dosage and was also given a lower dose of Tylenol than prescribed. The LPN administered 100 mg of Vitamin B6 despite the absence of a specified dosage in the physician's order and provided only 325 mg of Tylenol when the order was for 1,000 mg. The LPN acknowledged the need to clarify the Vitamin B6 order and confirmed the incorrect Tylenol dosage during the interview.