Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8.11% based on three errors out of 37 opportunities. Two residents were directly involved in these errors. In one instance, a certified medication aide (CMA) administered Fingolimod HCl and Sertraline HCl to a resident for personality disorder and anxiety, respectively, at 9:34 AM, despite both medications being ordered for administration at 8:00 AM. The delay was attributed to the facility's practice of timing routine morning medications for 9:00 AM due to CMA work schedules, although the physician orders specified an earlier time. The Director of Nursing (DON) and the administrator confirmed that CMAs' schedules and budgetary constraints contributed to the delay, and that nursing staff were expected to assist if delays were anticipated. In another instance, a CMA documented the administration of Cholecalciferol 1000 units for vitamin deficiency to a resident at 9:49 AM, but this medication was not observed as administered during the medication pass. The facility's policy requires that any dose withheld, refused, or given at a time other than scheduled must be properly notated in the electronic medication administration record (eMAR) and explained in the resident's progress notes, which was not done in this case. These actions and inactions resulted in residents not receiving medications as prescribed or not receiving them at all, as observed and documented by surveyors.