Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or lower, as evidenced by an error rate of 13.89% out of 36 opportunities. During a medication observation, an LPN was found administering medications to a resident outside the prescribed time frame. The medications, which included Bumetanide, Calcium Acetate, Carvedilol, and Ferrous Sulfate, were scheduled to be given at 9:00 AM, but were not administered until after 11:07 AM. The LPN admitted to being busy with other duties, which delayed the administration of the medications. Additionally, Vancomycin, which was ordered at midnight, was not in stock, and the LPN had to contact the physician and pharmacy to follow up on its availability. The Director of Nursing confirmed that the facility's policy allows for medications to be administered within an hour before or after the scheduled time. However, the delay in administering the medications and the unavailability of Vancomycin contributed to the high medication error rate. The facility's policy on medication administration emphasizes that medications should be administered as prescribed and within the designated time frame, but this was not adhered to in this instance, leading to the deficiency.
Plan Of Correction
1. What corrective action will be accomplished? Resident #379 showed no adverse effect from late medication administration (46 minutes). The physician for Resident #379 was notified of the late medication administration. No new orders were received. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: The DON/Designee conducted an audit of the AM (9:00AM) medication pass to ensure medications are administered timely. 3. Measures/systematic changes put into place: The pharmacy nurse consultant provided "med-pass" education/competency to licensed nurses. Med-pass education/competency will be added to licensed nurse new hire and annual education. Medication administration times will be reviewed by the DON and pharmacy consultant to ensure there is enough time to administer medications within the required time frame and adjust times as indicated. 4. How corrective action will be monitored: The DON/Designee will conduct daily (times 5 weeks) random audit observation of nurses AM (9:00AM) med-pass, to ensure that medications are administered timely. The results of this audit will be reviewed at the monthly QA meeting until compliance has been determined.