Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
Surveyors observed that the facility failed to ensure accurate administration of medications, resulting in a medication error rate of 7.14% during the review period. Specifically, two medication errors were identified out of 28 opportunities observed. One error involved a nurse administering only one capsule of Omega-3 (fish oil) to a resident, despite the physician's order for two capsules to be given orally twice daily. In the same observation, the nurse dispensed Voltaren Arthritis Pain (diclofenac sodium) gel by squeezing an unmeasured amount into a medication cup and applied it only to the resident's shoulders, omitting the lower back as specified in the physician's order. The nurse did not use a measuring tool to ensure the correct 2-gram dosage and was unaware of the specified amount in the electronic record. Interviews with facility staff confirmed that the expectation is for medications to be administered exactly as ordered by the physician. The nurse involved acknowledged not referencing a specific dosage for the topical medication, and both the Administrator and Director of Nursing reiterated the facility's policy of zero tolerance for medication errors and the requirement for staff to follow all physician orders precisely.