Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10% during a medication pass observation. Specifically, a registered nurse prepared a resident's scheduled morning medications but omitted spironolactone 25 mg, vitamin B12 1000 mcg, and furosemide 40 mg tablets. The nurse acknowledged forgetting to include these medications. Review of the resident's order summary confirmed these medications were prescribed to be given at 8:00 AM daily. Interviews with facility leadership indicated that nurses are expected to check the electronic medication administration record (EMAR) and verify medication rights prior to administration, as outlined in the facility's policy for safe oral medication administration.