Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 32%. During medication administration observations, 10 errors were identified out of 31 opportunities, affecting multiple residents. The errors included improper timing of medication administration, with medications being given outside the one-hour window before or after the prescribed time. Staff members, including LPNs, were observed administering medications late, and some staff reported being overwhelmed with additional responsibilities such as skin care, answering call lights, and communicating with families and doctors. Specific instances included a resident receiving a chewable tablet separated from other medications due to its form, and another resident's medication being delayed due to low vital signs. Staff interviews revealed that management was aware of the delays, and some staff had attended medication administration in-services. Despite these efforts, the issue persisted, with staff struggling to manage their time effectively, leading to significant delays in medication administration.
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. Resident #6 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. Staff A received re-education on by ADON on administering medications as per physician orders and notification to supervisor and/or physician if medications may be administered outside of scheduled time frame. Staff B received re-education on by ADON on administering medications as per physician orders and notification to supervisor and/or physician if medications may be administered outside of scheduled time frame. Staff C received re-education on by ADON on administering medications as per physician orders and notification to supervisor and/or physician if medications may be administered outside of scheduled time frame. Staff E received re-education on monitoring the timeliness of medication administration and facility process to follow specific to timeliness of medication.