Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.45% during the survey period. Specifically, two residents were observed receiving their prescribed intravenous antibiotics significantly later than scheduled. For one resident, Cefepime HCL was ordered to be administered every 12 hours for a urinary tract infection, with a scheduled dose at 9:00 AM. However, the medication was administered at 11:00 AM, two hours late. The nurse responsible acknowledged routinely administering medications late and incorrectly stated the frequency of administration. Another resident was prescribed Daptomycin to be administered intravenously every 24 hours for bacteremia, scheduled at 8:00 AM. The medication was given at 12:10 PM, four hours late. The nurse again admitted to consistently administering medications late. Interviews with nursing management confirmed that facility policy requires medications to be administered within one hour before or after the scheduled time, and any deviation outside this window is considered late. Review of the facility's policy corroborated this standard, and there was no documentation of physician notification for the late administrations.