Medication Error Rate Exceeded Due to Omitted and Improperly Administered Medications
Penalty
Summary
Surveyors determined that the facility failed to maintain a medication error rate below 5%, identifying three errors out of 36 medication administration opportunities, resulting in an 8.33% error rate. During a medication pass observation on 4/1/26 at 8:56 a.m., an LPN prepared a 40 mg Ingreeza capsule for a resident with an order for medications to be crushed, by softening the capsule in pudding rather than sprinkling the capsule contents in pudding as ordered. The LPN later confirmed that she did not prepare and administer the Ingreeza in accordance with the ordered method. In the same observation period, the LPN failed to administer the resident’s ordered 50 mcg/actuation fluticasone propionate (Flonase) nasal spray and 1 mg/mL olopatadine ophthalmic solution because these medications were not available. The LPN acknowledged that these medications were not given due to unavailability. The Assistant DON confirmed that the Ingreeza administration constituted a significant medication error, and the Nursing Home Administrator confirmed that the facility did not meet the requirement to remain free of a medication error rate of 5% or greater, based on the three identified errors out of 36 opportunities.
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