Medication Administration Errors and Dosing Deviations
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in four medication errors out of 26 opportunities, which equates to a 15.38 percent error rate. In one instance, a resident with metabolic encephalopathy and rhabdomyolysis was ordered a chewable 81 mg aspirin tablet but was instead given an enteric coated (EC) aspirin. Another resident with intestinal obstruction, hypertension, and peripheral vascular disease did not receive their ordered Folic Acid 1 mg tablet because it was not available at the time of administration, resulting in a missed dose. Additionally, a resident with a history of stroke and hypertension was ordered a chewable 81 mg aspirin tablet but was administered an EC aspirin instead. In a separate case, a resident with Parkinson's disease, rheumatoid arthritis, Cushing's syndrome, and diabetes mellitus type two was given polyethylene glycol 3350 measured with a liquid medication cup rather than the manufacturer-supplied cap, which is designed to ensure the correct dose. These errors were observed during medication administration and confirmed through staff interviews and review of physician orders and manufacturer directions.