Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with eight medication errors identified out of 26 observed opportunities, resulting in a 30.77% error rate. The errors involved the late administration of prescribed medications to three residents during observed medication passes. The facility's policy and staff interviews confirmed that medications are to be administered within a one-hour window before or after the scheduled time, but this protocol was not followed in multiple instances. For one resident with osteoarthritis, GERD, and a thoracic spine fusion, cyclobenzaprine was scheduled for 8 AM but was administered at 9:28 AM, outside the permitted window. Another resident with obstructive and reflux uropathy, hypertensive heart disease, and dementia was scheduled to receive five different medications between 8 AM and 9 AM, but all were administered at 10:26 AM, well past the allowed timeframe. A third resident with chronic kidney disease, atherosclerotic heart disease, and hypertension was scheduled to receive amlodipine and clopidogrel at 9 AM, but both were given at 10:52 AM. Staff interviews confirmed awareness of the facility's medication administration policy, which requires adherence to the scheduled times for medication administration to ensure consistency and accurate monitoring. Despite this, the observed medication passes did not comply with the policy, resulting in multiple late administrations and a medication error rate significantly above the acceptable threshold.