Medication Administration Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, with four errors identified out of twenty-nine opportunities, resulting in a 13.79 percent error rate. In one instance, a resident with severe cognitive impairment and a history of seizures and multiple sclerosis was administered Metoprolol despite a blood pressure reading below the ordered threshold, and was also given potassium chloride in a manner not consistent with the provider's instructions, as the pill was dissolved in water prior to administration without such an order. Staff interviews confirmed that these actions were not in accordance with facility expectations or provider orders. Additional deficiencies were observed involving other residents. One cognitively intact resident had an unidentified pill found on their bedside table, which was discarded by a CMA without identification or following the facility's protocol for handling unknown medications. Another cognitively intact resident had an over-the-counter medication (Orajel) at their bedside without a provider order or a completed self-administration assessment, contrary to facility policy. Staff interviews confirmed that these practices did not meet the facility's expectations for medication management and administration.