Medication Administration Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 4 errors in 26 medication administration opportunities, resulting in a 15.83% error rate. Facility policy on General Dose Preparation and Medication Administration, revised November 15, 2024, required nurses to verify that the medication administered is the correct medication, at the correct dose, for the correct resident. Review of Resident 66’s current physician orders showed an order for Cyanocobalamin (Vitamin B-12) 1000 mcg daily starting March 6, 2026, but observation on March 10, 2026, at 9:41 AM revealed that an LPN administered only 500 mcg of Cyanocobalamin to this resident. Review of Resident 93’s current physician orders showed Cyanocobalamin 4000 mcg daily, Aspirin 81 mg chewable tablet, and Senna 8.6 mg twice daily, but observation at the same time revealed that an RN administered Cyanocobalamin 500 mcg, Aspirin 81 mg enteric-coated instead of chewable, and Senna Plus 8.6 mg-50 mg (Senna 8.6 mg with docusate 50 mg) instead of Senna alone. In an interview, the Director of Nursing stated she would have expected the medications to be given in the form and dosages ordered, confirming that the observed administrations did not comply with physician orders and facility policy. These findings demonstrate that the facility did not ensure adherence to its own medication administration policy and physician orders during observed medication passes, resulting in multiple dose and formulation discrepancies for the residents involved and a medication error rate exceeding the regulatory threshold.
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