Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with observations revealing a 34.15% error rate during medication administration. Surveyors observed 41 medication administration opportunities and identified 14 errors involving four residents. These errors included missed doses, administration of expired medications, incorrect medication preparation, and failure to follow physician orders and facility policies. One incident involved a nurse searching for a prescribed calcium supplement and instead attempting to administer a different formulation before realizing the error. The nurse informed the resident that the correct medication was owed, but the medication order had been changed shortly after the observation. In another case, a nurse attempted to administer Midodrine to a resident despite the resident's blood pressure being above the hold parameter, only stopping after being prompted to review the order. The same nurse also prepared to administer expired insulin before obtaining a replacement from the emergency drug kit, but did not properly prime the insulin pen according to facility policy. Additional deficiencies included a nurse being unable to administer a prescribed antidepressant due to its unavailability, and another nurse failing to provide multiple ordered medications to a recently hospitalized resident due to missing medications and lack of reconciliation upon the resident's return. In several cases, staff did not follow procedures for obtaining or documenting unavailable medications, and there was a lack of timely communication with the pharmacy and physicians regarding medication availability. These actions and inactions directly contributed to the high medication error rate identified during the survey.