Medication Administration Errors
Penalty
Summary
The facility failed to ensure that physician orders were followed, resulting in a medication error rate of 32%, which is significantly higher than the acceptable threshold of 5%. During observations, interviews, and record reviews, ten medication errors were identified out of 31 opportunities, affecting four residents. The facility's policy on drug administration requires medications to be administered within one hour before or after their prescribed time, but this was not adhered to, leading to the high error rate. The errors were documented during a medication pass observation signed by the Consultant Pharmacist for a Licensed Practical Nurse (LPN).
Plan Of Correction
(1) Actions taken to correct the deficient practice: Resident #2 was evaluated on by the Unit Manager. There have been no ill effects noted from the medication errors. The physician and family were notified. The resident remains at the facility and is stable. Resident #3 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Resident #5 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable.