Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in three medication administration errors out of 35 observed opportunities. For one resident with hypertensive heart disease, pulmonary hypertension, and dementia, a Certified Medication Aide (CMA) administered two puffs of Anoro Ellipta inhaler instead of the prescribed one puff. The CMA acknowledged the error after administration. For another resident with Guillain-Barre syndrome, chronic respiratory failure, and COPD, a CMA prepared loratadine from an expired container and was preparing to administer it before being stopped by a surveyor. Additionally, the same CMA administered an olanzapine disintegrating tablet without instructing the resident to allow it to dissolve in the mouth, resulting in the resident swallowing the tablet whole. Both the CMA and supervisory nursing staff confirmed these were medication administration errors.