Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or lower, resulting in an observed error rate of 13.89% out of 36 opportunities. During a medication observation, an LPN on the Northside medication cart was found administering medications to a resident outside the prescribed time frame. The medications were scheduled to be given at 9:00 AM, with an acceptable administration window from 8:00 AM to 10:00 AM. However, the LPN had not administered the medications by 11:07 AM, citing being busy with other duties as the reason for the delay. Additionally, one of the medications was not in stock because it was ordered by the physician at midnight the previous night, and the LPN had to contact the physician and pharmacy to follow up on its availability. The facility's policy on medication administration states that medications should be administered within 60 minutes of the scheduled time unless specified otherwise by the prescriber. The Director of Nursing confirmed this policy during the survey. Despite this policy, the facility's medication distribution system failed to ensure timely administration, contributing to the high error rate. The surveyor's findings highlighted a lack of adherence to the established medication administration schedule and insufficient staffing or system processes to prevent unnecessary interruptions in medication administration.
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