Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during medication administration on two of three nursing units. During observed medication passes, there were 28 opportunities for medication administration, with two errors identified, resulting in a 7.14% error rate. One error involved a resident with atrial fibrillation, hypertension, and heart failure, who was prescribed Losartan Potassium 25 mg daily but was only administered 12.5 mg by an LPN, which was half the ordered dose. Another error involved a resident with dementia and gastroesophageal reflux disease, who was prescribed Protonix delayed release tablets, which should not be crushed; however, an LPN crushed the tablet prior to administration. The Director of Nursing confirmed that these medications were not administered according to physician orders.