Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 25 observed opportunities, resulting in a 12% error rate. During medication administration, a nurse gave a resident two vitamin B12 tablets instead of the prescribed cholecalciferol (vitamin D3) tablets for vitamin D deficiency. The nurse admitted to not verifying the medication against the physician's order and assumed vitamin B12 was correct. Additionally, the nurse administered two sprays per nostril of fluticasone propionate nasal spray for allergies, contrary to the physician's order of one spray per nostril, based on her belief that the full dose was not being delivered with a single spray. In another instance, the nurse administered levothyroxine sodium 50 mcg to the same resident while the resident was eating breakfast, despite the medication blister pack being labeled to give the medication on an empty stomach. The nurse acknowledged awareness of the administration instructions but did not check if any medications needed to be given before breakfast and proceeded to administer the medication after the resident had started eating. Interviews with the DON and pharmacist confirmed that the medications were not administered as ordered and that the nurse did not follow proper verification and administration procedures.