Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication errors out of thirty observed opportunities, resulting in a 6.67% error rate. One error involved a resident with immunodeficiency and a diagnosis of left pleural effusion, who was prescribed ceftriaxone 1 gram IV daily for ten days. On the observed date, the resident did not receive the scheduled dose of ceftriaxone at 9 a.m. because the RN did not have time to establish IV access until later in the morning, and the antibiotic was not administered as ordered. Another error involved a resident with diagnoses including gout, hypertension, depression, and muscle weakness, who was prescribed docusate 100 mg orally twice daily at 8 a.m. and 5 p.m. During the morning medication pass, the LPN administered docusate at 10:15 a.m., which was outside the facility's policy of a 60-minute window for scheduled medication administration. The LPN acknowledged that this was a medication error, as the medication was not given at the prescribed time. Interviews with nursing staff and the Director of Nursing confirmed that both errors were due to failure to follow physician orders and facility medication administration guidelines. The facility's policies require medications to be administered within one hour of the scheduled time and emphasize adherence to the five rights of medication administration, including the right time. Both errors were acknowledged by staff as deviations from these requirements.