Medication Error Rate Exceeds 5% Due to Incorrect Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 26 observed opportunities, resulting in an 11.5% error rate. Surveyors observed medication administration to five residents and identified errors involving three residents. The errors were identified through direct observation, staff interviews, and review of medication orders and administration records. One resident with end stage renal disease requiring hemodialysis was administered sevelamer, a phosphate binder, at a time not consistent with the physician's order, which specified the medication should be given with meals. The nurse administered the medication well before the scheduled dinner meal, providing only juice and crackers instead of a full meal, and was unaware that the medication was intended to be given specifically with meals. This action did not align with the prescribed instructions or the manufacturer's guidelines. Two other residents were administered a single ingredient medication containing only sennosides, rather than the prescribed combination medication of sennosides and docusate. In both cases, the staff members selected the incorrect medication from the stock bottles on the medication cart, failing to match the medication to the physician's order. Both the nurse and the medication aide involved acknowledged the error after reviewing the orders and the available medications, confirming that the combination medication should have been administered as ordered.