Medication Pass Errors Result in Exceeding 5% Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 30 medication administration opportunities, resulting in a 6.67% error rate. For one cognitively intact resident receiving medications for DVT prevention and constipation, review of physician orders showed a prescription for aspirin 81 mg chewable once daily and polyethylene glycol 3350 powder 17 g once daily. During a medication pass observation, a nurse removed and administered an 81 mg enteric-coated aspirin tablet from a stock bottle instead of the ordered chewable aspirin. The nurse later stated she did not notice that the aspirin she selected was enteric-coated rather than chewable. During the same observed medication pass, the nurse did not administer the ordered polyethylene glycol 3350, 17 g, to the same resident. In interview, the nurse explained that she did not give the polyethylene glycol because the resident typically refused it and she did not see the need to ask if he wanted the medication at that time. The resident reported that he moved his bowels every day to every other day and would inform nursing staff if he did not have a bowel movement within that timeframe. The DON stated an expectation that nurses administer medications according to physician orders, and the MD stated she expected nurses to look closely at the MAR and administer the medications as ordered.
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