Medication Administration and Documentation Errors Result in Elevated Medication Error Rate
Penalty
Summary
Surveyors determined that the facility failed to maintain a medication error rate below 5%, with an observed rate of 6.45%. During a medication pass observed at 9:18 AM, a registered nurse administered multiple medications, including Lasix 20 mg, a multivitamin, MiraLAX 17 g, Duloxetine 60 mg, allopurinol 100 mg, carvedilol 3.125 mg, vitamin B12, and lisinopril 5 mg. A subsequent review of the medication administration record at 12:38 PM revealed that Duloxetine 60 mg, ordered as a delayed-release capsule to be given by mouth at bedtime for depression, was instead administered during the morning medication pass. The review also showed an active order for Famotidine 20 mg by mouth once daily in the morning for GERD, which was not observed being administered during the medication pass but was documented on the medication administration record as having been given. These observed discrepancies between physician orders, actual medication administration times, and documentation on the medication administration record constituted medication errors that contributed to the facility’s medication error rate exceeding the 5% threshold.
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