High Medication Error Rate Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a medication error rate of 32.14 percent. This was identified during observation, interview, and record review, where nine medication errors were found out of 28 opportunities, all involving a single resident. The errors consisted of administering nine different medications at times different from those ordered by the physician. The resident involved had a history of difficulty walking, depression, dysphagia, and falls, and was assessed as having moderately impaired cognitive skills, requiring partial to moderate staff assistance for daily activities. The resident was prescribed multiple medications, including anastrazole, bupropion, carvedilol, furosemide, sertraline, vitamin C, thiamine, a multivitamin with minerals, and magnesium oxide, all scheduled for administration at specific times, primarily at 9:00 a.m. and 5:00 p.m. On the day of the observed deficiency, a nurse prepared and administered the resident's morning medications at 11:24 a.m., well past the scheduled 9:00 a.m. administration time and outside the facility's one-hour window policy. The nurse acknowledged being late due to being busy with other residents and confirmed that administering medications outside the prescribed time frame is considered a medication error. The facility's policy requires medications to be administered within one hour of the prescribed time unless otherwise specified.