Medication Administration Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, as evidenced by four errors out of 25 opportunities during observation, resulting in a 16% error rate. A resident with multiple diagnoses, including thoracic vertebra fractures, depression, anxiety, heart disease, and constipation, was observed during medication administration. The registered nurse (RN) administered incorrect medications and dosages, including giving enteric coated aspirin instead of chewable aspirin, buspirone 5 mg instead of the ordered 10 mg, and senna 8.5 mg instead of the ordered 8.6-50 mg. Additionally, the I-vite supplement was not administered, though it was documented as given. Further observations revealed lapses in medication security and documentation. The RN left the medication administration record open and out of sight, left a sealed lidocaine patch unattended on top of the medication cart, and failed to lock the medication cart when leaving it unsupervised. The RN also did not label the medication bubble pack to indicate a change in the buspirone order, as required by facility policy. These actions were inconsistent with the facility's medication administration and storage procedures, contributing to the identified deficiency.