Medication Error Rate Exceeds 5% Due to Improper Administration and Documentation
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 6.45% during medication administration. Out of 31 medication administration opportunities, two errors were identified involving one resident. During observation, an LPN crushed five medications together, mixed them with yogurt, and administered them to a resident. Additionally, Polyethylene glycol 3350 was mixed with water and only partially consumed by the resident, but was documented as fully administered by the LPN. Review of the resident's physician orders revealed that levothyroxine 75mcg was to be given 30-60 minutes before breakfast, separate from food and other medications, and separated by four hours from antacids, iron, or calcium products. The LPN confirmed that levothyroxine was mixed with other medications and yogurt, contrary to the physician's instructions. The Unit Manager also confirmed that this constituted a medication error. Facility policy requires staff to be knowledgeable about medications and to check orders before administration, which was not followed in this instance.