Medication Error Rate Exceeds Acceptable Threshold Due to Omission and Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in an observed error rate of 8.33% during medication administration for two out of five residents. For one resident with multiple chronic conditions, including diabetes, hypertension, and macular degeneration, the morning medication pass was observed to be incomplete. The resident did not receive a scheduled dose of fish oil, and there was uncertainty regarding the application of a prescribed topical lotion. The LPN responsible for medication administration also delayed giving a dose of Senna due to its absence from the medication cart, retrieving it later and adding it to the same medication cup as the other pills. Documentation on the Medication Administration Audit Report did not reflect the administration of fish oil, and the timing of other medications was inconsistent with observed administration times. Another resident, with a history of paraplegia, chronic pain, and musculoskeletal issues, was prescribed aspirin in capsule form for pain management. During the observed medication pass, the nurse dispensed a chewable aspirin tablet instead of the ordered capsule and placed it with the other oral medications. The resident swallowed the chewable tablet whole, rather than chewing it as intended. The nurse confirmed that the facility did not have the prescribed capsule form available and substituted with a chewable tablet without adjusting the administration method or order. Facility policy required medications to be administered as prescribed, within 60 minutes of the scheduled time, and for staff to verify medication orders against labels, ensuring the right medication, dose, route, and time. The observed incidents demonstrated non-compliance with these policies, as medications were omitted, substituted without proper adjustment, and not administered according to the prescribed method or schedule.