Medication Administration Errors Result in Elevated Medication Error Rate
Penalty
Summary
Surveyors identified a medication error rate of 8% (2 errors out of 25 opportunities), exceeding the required rate of less than 5%. In the first instance, a medication aide administered Breo Ellipta 200-25 mcg inhalation powder as one puff by mouth to a resident with an order initiated on 12/24/25 for reactive airway disease. The physician’s order and the manufacturer’s prescribing information both specified that after inhalation the patient should rinse the mouth with water and spit it out to help reduce the risk of oropharyngeal candidiasis. During observation, after the resident inhaled one puff of Breo Ellipta, the medication aide offered water, which the resident drank and swallowed immediately. The aide did not prompt the resident to rinse and spit as required by the order. Subsequent review of the MAR and interview confirmed that the order included the rinse-and-spit notation and that the aide had allowed the resident to swallow the water instead. In the second instance, the same medication aide prepared and administered a multivitamin with minerals taken from a stock bottle on the medication cart to another resident. The current physician’s order for this resident, initiated on 7/17/24, specified a multivitamin without minerals to be given once daily for vitamin deficiency. During interview and review of the MAR, the nurse confirmed that the order was for a multivitamin only, without added minerals. The medication aide acknowledged uncertainty about whether a stock bottle containing only multivitamins (without minerals) was available on the cart, and the nurse indicated that such a bottle was present. The aide had not verified the stock bottle label closely enough and administered a multivitamin with minerals instead of the ordered multivitamin without minerals, constituting a second medication error contributing to the elevated error rate.
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