Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
Surveyors observed that the facility failed to maintain a medication error rate of five percent or less during medication administration, with two errors identified out of 25 opportunities, resulting in an eight percent error rate. One incident involved a resident with dysphagia, hypokalemia, dementia, and atherosclerotic heart disease, who had a physician order for potassium chloride extended release (ER) 20 mEq to be dissolved in water and not crushed. An LPN crushed the potassium chloride ER tablet and administered it in a supplement drink, contrary to the physician's order and medication guidelines. The LPN confirmed the error during an interview, and the facility pharmacist verified that the medication should not have been crushed due to its extended-release formulation. Another incident involved a resident with dementia and a fractured right femur, who had a physician order to receive two tablets of calcium carbonate-vitamin D 500 mg-5 mcg twice daily. An LPN prepared and administered only one tablet, instead of the prescribed two, and documented the administration as complete. The LPN acknowledged the error during an interview. Facility policy required staff to verify whether medications could be crushed and to check the medication label three times to ensure the correct resident, medication, dose, time, route, and documentation, but these procedures were not followed in the observed cases.