Medication Error Rate Exceeds Acceptable Threshold Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with three medication errors occurring out of 30 observed opportunities, resulting in a 10 percent error rate. During medication administration for one resident with diagnoses including rhabdomyolysis, type II diabetes mellitus, and hypertension, it was observed that three prescribed medications—Mucinex 600 mg, Fluticasone Propionate nasal spray, and glipizide 5 mg—were not administered as ordered due to the medications not being available in the facility. The LPN responsible for administering the medications confirmed that the medications were not given because they were not on hand and stated that this issue occurs frequently. Facility policy requires verification of the right medication, dose, time, and route before administration, but the lack of medication supply prevented compliance with these requirements.