Medication Administration Errors Resulting in 12% Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, as required, resulting in a calculated error rate of 12% during an observed medication pass. Surveyors observed 25 medication administration opportunities and identified 3 errors involving two residents. Facility policy on administering medications, revised April 2019, states that medications are to be administered safely, timely, and as prescribed, and that the individual administering the medication must check the label three times to verify the right resident, medication, dosage, time, and route before administration. For one resident, an LPN administered Sertraline HCL 25 mg by mouth instead of the ordered Sertraline HCL 50 mg once daily. The nurse later reviewed the physician’s orders and the medication card and confirmed that the dose given was incorrect and that she had failed to verify the dosage prior to administration. For another resident, a different LPN administered Zinc 50 mg instead of the ordered Zinc Sulfate 220 mg, and Vitamin D3 10 mcg instead of the ordered Vitamin D3 1250 mcg given on specific mornings. This nurse also confirmed, upon review of the physician’s orders and medication containers, that both dosages were incorrect and acknowledged she had not checked the medication dosages prior to administration. The DON stated he expected staff to check medications against physician orders prior to administration and confirmed medications should be given in the correct dosage as ordered by the physician.
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