Medication Administration Errors Resulting in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying six errors out of 25 opportunities, resulting in a 24% error rate. For one resident with type 1 diabetes mellitus, underweight, and tachycardia, the medical record showed an order for carvedilol (Coreg) 12.5 mg by mouth twice daily, scheduled for 9:00 A.M. Observation and interview on 02/11/26 at 10:31 A.M. revealed that LPN #66 administered the Coreg at 10:31 A.M., and the nurse confirmed this was outside the one-hour window for the scheduled 9:00 A.M. dose. Another resident, with chronic kidney disease stage two and type 2 diabetes mellitus, had physician orders for duloxetine 60 mg, famotidine 20 mg, MiraLAX 17 gm, Norvasc 2.5 mg, and metformin 500 mg twice daily, all ordered to be given by mouth and scheduled for 9:00 A.M. Observation and interview on 02/11/26 at 11:30 A.M. showed that LPN #59 administered all five medications via the resident’s gastrostomy tube instead of orally and confirmed that these medications, including metformin, were scheduled for 9:00 A.M. and that she always administered them late. The DON later verified there were no orders for these medications to be given through the G-tube and that they were ordered only by mouth. These findings were cited under Complaint Number 1363724 (OH00165691).
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