Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 13.33% based on four medication errors out of thirty opportunities. Surveyors observed multiple instances where nursing staff did not follow physician orders or facility policy during medication administration. For example, a registered nurse crushed potassium chloride extended-release capsules for two residents, despite clear physician instructions and labeling that the medication should not be crushed. In both cases, there were no physician orders or care plan indications permitting the medications to be crushed. Another resident was observed chewing a potassium chloride capsule, which was not administered with water as required by FDA guidelines and facility policy. The nurse did not document the resident's difficulty swallowing the medication, nor was the physician notified that the resident did not receive the full prescribed dose or that a change to a liquid form might be needed. Additionally, a nurse failed to shake a bottle of senna oral syrup before administration and combined the unshaken liquid with other crushed medications in coffee, again without a physician's order or care plan direction to do so. The Director of Nursing confirmed that medications labeled as "do not crush" should not be altered without a physician's order, and that proper procedures for medication administration, documentation, and disposal were not followed in these cases. Facility policy also requires hand hygiene between residents, destruction of unused medications, and notification of the physician if a resident does not take medications as prescribed, none of which were consistently observed during the survey.
Plan Of Correction
The facility will develop a plan to maintain a medication error rate of 5% or less. For Resident #95, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #8, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #70, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #23, a review of bowel movements was completed by DON to assure that the resident did not have any unusual increased or decreased frequency of bowel movements. The resident was also monitored through daily nursing notes and CNA task documentation. ADON identified all residents who receive potassium and all who receive crushed, opened, or modified medications that had the potential to be affected. Immediate 1:1 education was given to nurses in the facility on Do Not Crush medications. DON and ADON reviewed the Medication Administration Policy and updated the Oral Crushed Medication section to reflect that a physician order is needed to crush any medication and to administer multiple crushed medications together. DON and ADON completed a Root Cause Analysis (RCA). They created a Relias module and posttest reinforcing the following: - If a pill is dropped onto the cart or floor, place it in the Drug Buster and retrieve a new pill to administer. - Shake well to mix suspensions. - Crushed medications require a Physician order to crush. - Potassium orders require a DO NOT CRUSH order but may be opened and sprinkled. - If a resident refuses medications, document in EHR and notify the Charge Nurse. - If medication has been prepared and then refused, destroy it in the Drug Buster. - Perform hand hygiene prior to administering medication. - Perform hand hygiene after medication administration. - If a resident is displaying difficulty with any medication (e.g., taste, form, size), notify the physician. - For employees who are casual/student status, on vacation, or on leave of absence (LOA), training will be completed before or during their next scheduled shift. DON provided a full list of residents who receive crushed medications to DNP for review and to write an order for long-acting medications indicating: 1) Do Not Crush OR 2) Do Not Crush, but may open and sprinkle and combine OR 3) May crush and Do NOT combine OR 4) May crush and combine Once orders are processed, MDS will update the Care Plan to reflect this. DON created a new form: Refusal of Medication/Medication Change Request Form, for charge nurses (notified by neighborhood nurses) to fill out for residents who may require a change in medication for any reason. Completed forms will be given to DNP for any necessary action. DON verified that audits are performed monthly by the pharmacy consultant for any residents who should have an order stating Do Not Crush. The Omniviews DO NOT CRUSH medication list was added to all units' medication information binders, placed at the north side nurses' station, and given to Administrative Medical Assistants. To ensure the policy review and changes are followed, DON/ADON or designee will randomly audit a medication pass with a focus on: - Medications are not being altered or combined without an order - No prepared medication stored in the medication cart - Performing hand hygiene - Medication disposed of appropriately if contaminated or refused - Shaking of liquid medications - Notification to the charge nurse for medication refusal Audits will occur on two nurses weekly on each shift for one month, then one nurse on each shift weekly for two months, and then one nurse monthly on an ongoing basis to ensure compliance with facility guidelines. The pharmacy consultant will audit residents' orders monthly and ensure Do Not Crush orders are present for medications that should not be crushed, sending recommendations if an order is missing. The MDS coordinator or designee will conduct quarterly audits to verify that any resident on crushed, opened, modified, or combined medications has a corresponding intervention in their care plan. DON will present a compliance report based on the audit findings at monthly QAPI meetings for review by the team for three months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. Ongoing monitoring thereafter will be continued by DON to ensure compliance in accordance with the plan of correction. DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Medication error rate exceeded the required threshold when an RN administered Amlodipine and Losartan Potassium to a resident despite a pulse below the ordered hold parameter of 60. The resident had HTN, hypotension, Parkinsonism, and moderate cognitive impairment. The RN acknowledged the error, and the DON and ADM stated they were unaware the physician orders had not been followed until after the observation.
Medication Administration Errors Exceeded Allowed Rate: The facility had a 5% med error rate based on 2 errors in 40 opportunities. During observation, an MA gave one resident guaifenesin 400 mg instead of the ordered 600 mg dose, and gave another resident cranberry 450 mg instead of the ordered 500 mg dose. The MA stated she caught one error but missed the other, while the DON said he was unsure when staff last received med admin training and the ADM expected staff to verify the correct dose before giving meds.
An LPN administered nine oral medications to a resident 1 hour and 36 minutes late, despite provider orders specifying an 8:00 AM administration time. Surveyors found nine errors in 31 medication administration opportunities, and the DON stated the expected medication window was 1 hour before and 1 hour after the ordered time.
Medication administration error rates exceeded the allowed threshold when an MA gave scheduled meds to two residents after the ordered 9:00 a.m. time. One resident had dementia, HTN, atherosclerosis, and clotting-related diagnoses and received acetaminophen, warfarin, atenolol, and enalapril late; another resident with HTN, depression, anxiety, and chronic pain received amlodipine, duloxetine, gabapentin, and Gemtesa late. Staff interviews confirmed expectations for timely administration, and the facility policy reviewed did not include a specific medication-time policy.
Medication Error Rate Exceeded Allowed Threshold: An LPN prepared and nearly administered two incorrect medications for a resident, including a BP medication without checking the resident’s BP despite a hold parameter and Meclizine at 25 mg instead of the ordered 12.5 mg. The survey found the facility’s medication error rate was 8% (2 errors out of 25 opportunities), exceeding the required rate of less than 5%.
Medication error rate exceeded the allowed threshold after surveyors found 3 errors in 25 opportunities. An RN gave insulin at an inappropriate site for a resident with DM and severe cognitive impairment, and a Med Aide failed to administer ordered eye drops and did not give the full ordered dose of a laxative for another resident with severe cognitive impairment. The DON stated staff were expected to audit and replenish carts and notify nursing if OTC meds were needed.
Medication Given Outside Ordered Vital Sign Parameters
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent. Surveyors found an 8 percent medication error rate based on 2 errors out of 25 opportunities, involving 1 of 3 residents reviewed for medication administration. The deficiency centered on Resident #81, an [AGE]-year-old female admitted on 03/06/2026 with diagnoses including hypotension, candidiasis, essential primary hypertension, Parkinsonism, and cognitive communication deficit. Her quarterly MDS dated 06/09/2026 showed a BIMS score of 08, indicating moderate cognitive impairment. Resident #81 had physician orders for Amlodipine 5 mg daily and Losartan Potassium 50 mg twice daily, both with instructions to hold if pulse was less than 60. During a medication administration observation, RN A checked the resident’s vital signs before giving the medications and obtained a blood pressure of 129/65 and a pulse of 57. Despite the pulse being below the ordered parameter, RN A administered both Amlodipine and Losartan Potassium and then documented the medications as given on the MAR. During interview, RN A stated the resident should not have received either medication because the pulse was below the ordered parameter and acknowledged that she made an error and did not realize the pulse was below the set parameters at the time of administration. The DON and ADM stated they were not aware the orders had not been followed until after the observation and confirmed that nursing administration was responsible for ensuring medications were given according to physician orders. The facility policy stated medications are to be administered in accordance with prescriber orders and that vital signs are checked and verified when necessary before administration.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate was less than 5 percent. Based on observation, interview, and record review, the facility had a medication error rate of 5% based on 2 out of 40 opportunities for 2 of 4 residents reviewed for medication administration. The errors involved MA G giving Resident #56 guaifenesin 400 mg instead of the ordered Mucinex oral tablet extended release 12 hour 600 mg, and giving Resident #47 cranberry 450 mg instead of the ordered cranberry soft oral tablet chewable 500 mg. Resident #56 was a [AGE] year-old male admitted and readmitted with diagnoses including acute respiratory failure, protein-calorie malnutrition, and quadriplegia, and had a physician order for guaifenesin 600 mg once daily for cough. During medication administration observation, MA G dispensed guaifenesin 400 mg to the resident. Resident #47 was a [AGE] year-old male admitted and readmitted with diagnoses including acute respiratory failure, immunodeficiency, and neuromuscular dysfunction of bladder, and had an order for cranberry 500 mg twice daily related to neuromuscular dysfunction of bladder. During observation, MA G dispensed cranberry 450 mg to the resident. MA G stated she caught the error for Resident #56 and another nurse obtained the correct dose, but she did not notice the wrong dose for Resident #47 and stated it was her fault. The DON stated he was unsure when staff last received medication administration training and was not aware of such training during his time as DON. The ADM stated staff were expected to verify the correct dose before giving medications.
Medication Administration Timing Error Exceeded Allowed Error Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent. During observation, interview, and record review, surveyors found that Staff J, an LPN, prepared and administered nine oral medications to Resident 96 at 9:36 AM even though the provider’s orders for June 2026 specified that the medications were to be given at 8:00 AM. The medications were administered one hour and 36 minutes late, and this accounted for nine errors in 31 opportunities during medication administration for 1 of 6 sampled residents reviewed for medication administration. During interview, Staff J stated nurses had up to two hours to administer medications after the ordered time, while the DON stated the medication administration time was one hour before and one hour after the specific time of the order and that the nurse’s practice did not meet expectations.
Medication Administration Times Not Followed
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5 percent. Surveyors observed a medication error rate of 32% based on 8 errors out of 25 opportunities, involving two residents and one medication aide during medication administration observations. The errors involved medications being administered outside the scheduled administration window for two residents. Resident #2 was an older male admitted with diagnoses including unspecified dementia, hypertensive heart disease, atherosclerosis of the aorta, and embolism and thrombosis of arteries of the extremities. His medication orders included acetaminophen, warfarin, atenolol, and enalapril, with scheduled administration times of 9:00 a.m. During observation, MA A began preparing and then administered Resident #2's medications at 10:30 a.m. to 10:36 a.m., after the scheduled time shown on the eMAR. MA A stated the medications were due at 9:00 a.m. and said she did not get there until 9:00 a.m. Resident #3 was an older female admitted with diagnoses including hypertensive heart disease, major depressive disorder, anxiety, and chronic joint pain. Her orders included amlodipine, duloxetine, gabapentin, and Gemtesa, with scheduled administration times of 9:00 a.m. for the daily medications and 9:00 a.m., 1:00 p.m., and 5:00 p.m. for gabapentin. During observation, MA A prepared and administered Resident #3's medications at 10:36 a.m. to 10:40 a.m., after the scheduled 9:00 a.m. time shown on the eMAR. Interviews with LVN C, LVN B, and the DON reflected that staff were trained on medication administration times and that medications should generally be given within one hour before or after the scheduled time, with notification to the MD, DON, ADON, and family if given late. The facility's policy titled Administering Oral Medications did not include a specific policy regarding medication administration times, and the referenced Administering Medications policy was not available.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with a documented error rate of 8% based on 2 errors out of 25 opportunities. During a medication administration observation with an LPN, Resident #81’s medications were prepared using the electronic medical record, and the nurse retrieved one Olmesartan/amlodipine/hydrochlorothiazide 40/10/25 mg tablet and one Meclizine 25 mg tablet and placed them in a medication cup. The nurse entered the resident’s room and placed the cup on the resident’s table, stating, “here’s your medication,” before the surveyor intervened and directed review of the physician orders. Review of the resident’s orders showed the Olmesartan/amlodipine/hydrochlorothiazide order included instructions to hold the medication if systolic blood pressure was less than 100, but the nurse had not checked the resident’s blood pressure before administration. The orders also showed Meclizine was prescribed at 12.5 mg, not the 25 mg tablet the nurse had prepared. In interview, the LPN confirmed she was prepared to administer the medications as set up, was unaware of the resident’s blood pressure status, and confirmed the Meclizine dose was incorrect. The unit manager stated medications were expected to be administered according to physician orders, with required vital signs obtained and medication dosage checked before administration. The resident’s care plan identified the resident as at risk for fluctuation in blood pressure and directed staff to administer medications as directed.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure that its medication error rate was not 5 percent or greater. Surveyors identified 3 medication errors out of 25 opportunities, resulting in a 12.0% error rate during medication administration observations for two residents. The report states that these failures could place residents at risk for incomplete therapeutic outcomes and decline in health. For one resident with Type 2 DM with hyperglycemia, cerebral infarction, heart failure, and severe cognitive impairment, RN A administered Novolog insulin at the resident’s deltoid area after the resident exposed her right arm, even though RN A stated insulin should be injected into fatty tissue in a subcutaneous area. The resident’s blood glucose was 255, and RN A had prepared both Novolog and Toujeo before entering the room. RN A stated she automatically gave the Novolog on the arm because the resident wanted it there. For another resident with constipation, essential hypertension, cerebral infarction, and severe cognitive impairment, MA A administered several oral medications but did not give the ordered artificial tears because they were not in the cart. MA A said she would get the medication from central supplies, went to an unidentified door, and then returned and signed off the EMAR after no one answered. Medication reconciliation later identified that the resident was also supposed to receive 2 tablets of Sennosides, and the DON stated staff were expected to audit and replenish carts and notify the nurse or unit manager if OTC medications were needed.
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