Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 7.14% during the survey period. Specifically, two medication errors were observed among 28 medications administered to residents. In one instance, a resident with a history of alcohol abuse, depression, and anxiety, and exhibiting moderate cognitive impairment, was prescribed 75 mg of Sertraline (Zoloft) to be administered in the morning. However, the LPN administered only 25 mg, which was confirmed by both observation and subsequent interview with the nurse involved. In another case, a resident with diagnoses including alcohol abuse, muscle weakness, and difficulty walking, and also exhibiting moderate cognitive impairment, was prescribed Thiamine 100 mg daily. During medication administration, the LPN failed to administer the ordered Thiamine, despite documentation indicating it had been given. The DON later confirmed that the Thiamine was not administered as ordered and was located on another medication cart. These events were verified through record review, direct observation, and staff interviews, demonstrating non-compliance with the facility's medication management policy.