Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered at the prescribed times, resulting in a medication error rate of 22.22%, which exceeds the acceptable threshold of 5%. This deficiency was observed through the cases of two residents. The first resident, admitted with multiple diagnoses including diabetes mellitus type II and dementia, had a medication schedule that required blood sugar checks and insulin administration at specific times. However, on one occasion, the resident's blood sugar was checked and insulin was administered significantly later than scheduled, after breakfast, which could lead to inaccurate blood sugar readings and potential health risks. The second resident, with a history of conditions such as idiopathic progressive neuropathy and Alzheimer's disease, was scheduled to receive tramadol for pain management at specific times. However, the medication was administered late, outside the facility's policy of allowing a one-hour window before and after the scheduled time. The Director of Nursing confirmed that medications should be administered within this window and that blood sugar checks should occur before meals to ensure accuracy. The facility's failure to adhere to these protocols contributed to the high medication error rate.