High Medication Error Rate During Medication Pass
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a medication error rate of 46.67% during a medication pass for one resident. Fourteen medication errors were identified out of thirty opportunities for a resident with multiple diagnoses, including chronic kidney disease, hypertension, diabetes mellitus, and osteomyelitis. The errors were observed during a medication administration round, where the nurse administering the medications stated she was running late and had notified the physician that the medications would be administered late. Record review showed that the resident was prescribed a complex medication regimen, including antihypertensives, insulin, anticoagulants, and other medications. Facility policy required medications to be administered within one hour of the scheduled time unless otherwise specified, and in accordance with prescriber orders. The observed practice did not align with these policies, as medications were not administered as ordered, contributing to the high error rate.