Medication Error Rate Exceeds Regulatory Limit Due to Timing and Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy and regulation. During observation of 27 medication administrations, 13 errors were identified involving three residents. Errors included administering medications at incorrect times, such as giving Levothyroxine and Omeprazole to a resident while they were eating breakfast instead of the required time before meals, and failing to administer Cariprazine due to unavailability. Another resident received all scheduled morning medications late, and a third resident also received all morning medications late, with one medication (Carvedilol) administered without food as required, since the resident had not eaten nor been provided a snack. These deficiencies were confirmed through interviews with the medication aide, who acknowledged the timing errors, the lack of medication availability, and the failure to provide food with certain medications. The facility's own policies require adherence to the six rights of medication administration, including correct timing and administration with food when indicated, but these standards were not met during the observed medication passes.