Medication Error Rate Exceeded Due to Methadone Dose Discrepancy and Inhaler Instructions Omission
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 2 errors identified out of 37 medication administration opportunities, resulting in a 5.41% error rate. In the first instance, an LPN prepared Methadone for a resident with a physician order for Methadone HCl oral solution 75 mg by mouth twice daily for maintenance. During medication preparation, the LPN stated she was going to administer 75 mg and handed the Methadone container to the surveyor, who observed the bottle was labeled 74 mg. When prompted, the LPN read the bottle label as 74 mg and the electronic order as 75 mg but did not initially recognize the discrepancy between the ordered dose and the labeled dose. Only after further questioning by the surveyor did the LPN acknowledge that the Methadone container dosage did not match the physician’s order. In the second instance, an RN administered an Anoro Ellipta inhaler to another resident who had a physician order for one puff daily for COPD with instructions to rinse the mouth with water and expectorate after use. The surveyor observed the RN give the resident a puff of the Ellipta inhaler, after which the resident took a sip of water. The RN did not provide any instructions to the resident to rinse and spit out the water, and the resident did not perform the ordered mouth-rinsing and expectoration. When the surveyor later raised this concern, the RN acknowledged and understood that the resident had not followed the ordered post-inhalation mouth care instructions.
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