Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, resulting in a 12% error rate during the observed period. Three medication errors were identified out of 25 opportunities, affecting three residents. Specifically, one resident received aspirin at a time different from the physician's order, another received a multivitamin with minerals instead of the prescribed multivitamin without minerals, and a third resident received carvedilol at a time inconsistent with the physician's order. Observations and interviews revealed that the errors were due to deviations from prescribed medication administration times and incorrect medication selection. Nursing staff acknowledged administering medications outside the facility's 60-minute window for scheduled doses and providing a formulation of a supplement that did not match the physician's order. The staff involved recognized these incidents as medication errors during interviews and explained the discrepancies between the orders and the actual administration. Record reviews confirmed the physician orders for each resident, including specific instructions regarding timing and formulation of medications. Facility policies required medications to be administered as prescribed, within a one-hour window of the scheduled time, and for staff to verify the correct medication, dosage, time, and route before administration. The documented errors occurred despite these policies, as staff failed to adhere to the established guidelines and physician orders.