State Findings:
Ensure medication error rates are not 5 percent or greater.
45813
Based on observation, record review, and staff interview, the facility failed to ensure the medication error rate was less than five per cent (5%). A total number of 35 medication opportunities were observed, and there were three errors for two of four residents (R) (R#54) and (R#72) by two of three certified medication aides (CMA) observed giving medications, for an error rate of 8.57%.
Findings include:
On 5/25/22 at 7:07 a.m., Certified Medication Aide (CMA) FF was observed giving R#54 her morning medications. Observation revealed that medicines given included Aspirin 81 mg (milligrams) chewable 1 tablet, Cranberry Extract 450 mg 1 tablet, Loratadine 10 mg 1 tablet, Vitamin C 500 mg 1 tablet, Vitamin D3 25 mg 5 tablets, Aripiprazole 5 mg 1 tablet, Losartan Potassium 100 mg 1 tablet, Memantine HCL 10 mg 1 tablet, Metoprolol Succinate 50 mg 1 tablet, and Venlafaxine HCL 37.5 mg 1 tablet. After all of the resident’s morning medications had been prepared, CMA FF counted the number of pills in the cup, and verified during interview that what she prepared was all of the medications R#54 received for that time of day.
Review of R #54’s May Physician’s Orders in the electronic medication record revealed an order for Aspirin 81 mg delayed release 1 tablet. During the medication observation with CMA FF on 5/25/22 at 7:07 a.m., CMA FF verified that she administered ASA 81 mg chewable 1 tablet.
On 5/25/22 at 7:22 a.m. during medication observation surveyor observed CMA BB administer the following medications to R#72; Clopidogrel 75 mg 1 tablet, Hydrochlorothiazide 12.5 mg 1 tablet, Montelukast Sodium 10 mg 1 tablet, Levetiracetam 25 mg 1 tablet, Potassium Chloride 10 meq 1 tablet and Sertraline HCL 25 mg 1 tablet. Surveyor observed CMA BB remove 2 Flovent Inhalers from the mediation cart for administration for R#72. CMA BB asked resident to rinse her mouth with water before and after the administration of the Flovent Inhaler. CMA BB then attempted to administer the second inhaler (Flovent); surveyor intervened and asked CMA BB to step outside with both inhalers. CMA BB verified that the second inhaler was another Flovent inhaler and not the scheduled Combivent inhaler. CMA BB stated, I got mixed up.
Review of R#74’s electronic medication record revealed that resident has an order for Multivitamin with Minerals 1 tablet, which was not administered with the morning medications. CMA BB verified she did not administer the scheduled medication.
Review of facility’s policy titled Pharmacy Services Medication Administration General dated 2019 reads medications are administered as prescribed, in accordance with good nursing principles.
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