Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11% with 5 errors out of 43 opportunities. Specific incidents included a nurse failing to administer a prescribed topical analgesic to a resident as ordered, and another nurse not administering an antihypertensive medication due to low blood pressure, subsequently storing the medication in an unlabelled cup in the medication cart and later administering it without confirming the resident's blood pressure status. Additionally, a nurse administered the wrong topical medication to a resident, substituting a lidocaine and prilocaine cream for a prescribed lidocaine patch. Two further errors involved the non-administration of prescribed medications (an iron supplement and a diabetes medication) due to unavailability, with staff confirming that the residents did not receive these medications as ordered. Interviews with staff and the pharmacist confirmed that all residents should receive medications as per physician orders, and the Director of Nursing also acknowledged this expectation. The observed failures included both omissions and incorrect administration of medications, as well as improper medication handling and storage practices, directly contributing to the elevated medication error rate identified during the survey.