Medication Administration Errors Exceed Acceptable Error Rate
Penalty
Summary
Surveyors identified that the facility failed to ensure medications were administered as prescribed, resulting in a medication error rate of 8% (2 errors out of 25 opportunities), which exceeded the 5% threshold. For one resident (R245), the Physician Order Sheets documented an order for Folic Acid 400 mcg once daily and Aspirin 81 mg once daily, scheduled for 9:00 a.m. During a medication pass observation at 9:12 a.m., an LPN (V27) prepared and was ready to administer chewable Aspirin 81 mg and Folic Acid 1,000 mcg to this resident. When questioned, the LPN confirmed that chewable Aspirin had not been prescribed for the resident and acknowledged that the Folic Acid dose in hand was 1,000 mcg instead of the ordered 400 mcg. The facility’s undated drug administration policy requires that medications be administered as prescribed, in accordance with written physician orders and good nursing principles and practices, and within 60 minutes of the scheduled time. These observations, interviews, and record reviews demonstrated that the nurse did not follow the resident’s current physician orders or the facility’s medication administration policy when preparing the incorrect formulation of Aspirin and the incorrect dose of Folic Acid for administration.
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