F0759

D

Medication Error Rate Exceeds 5% Due to Incorrect Dosing

Oklahoma City, Oklahoma Survey Completed on 02-18-2026

Penalty

Fine: $50,116

Summary

The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 7.41% during a medication pass observation involving four sampled residents, with two residents receiving incorrect doses. For one resident, a CMA administered one tablet of vitamin D3 25 mcg from house stock instead of the prescribed vitamin D3 50 mcg, and later acknowledged that two 25 mcg tablets should have been given to follow the physician’s order. For another resident, a CMA administered one tablet of senna despite a physician’s order for two tablets once daily for constipation, and subsequently confirmed that only one tablet had been given instead of the ordered two. The DON stated that staff were expected to follow the rights of medication administration, use the punch-initial-give method, and adhere to physician orders.

The administrator reported that 63 residents resided in the facility at the time of the survey, and the identified errors during the observed medication pass contributed to the facility’s overall medication error rate exceeding the 5% threshold.