Medication Error Rate Above 5% Due to Incorrect Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 38 medication administration opportunities, resulting in a 5.26% error rate. During a medication pass observation, a nurse prepared and administered two 100 mg capsules of docusate sodium from a stock bottle to a resident. Record review showed that this resident did not have an order for docusate sodium 100 mg, but instead had an active order, dated 5/29/25, for two tablets daily of a combination product containing sennosides and docusate sodium 8.6-50 mg. The nurse later stated she had not realized she had administered the wrong type of stool softener. In a separate observation with another resident, the same nurse removed and administered one tablet of Calcium 600 mg with Vitamin D 5 mcg from a stock bottle. Record review revealed that this resident had an order, dated 1/8/26, for calcium citrate 950 mg (200) one tablet daily, with the 200 indicating the amount of elemental calcium. The nurse reported that the facility had only one dosage of calcium stocked and that she administered what was available in stock rather than the specifically ordered calcium citrate. The DON later confirmed that the calcium citrate order originated from the hospital and was continued on admission, and that there had been no prior verification with the physician regarding the discrepancy between the ordered calcium supplement and what the facility had in stock.
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