Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy and regulation. Out of 31 observed medication administration opportunities, there were 2 medication errors, resulting in an error rate of 6.5%. The errors involved two residents. In the first instance, a resident was administered acetaminophen earlier than the scheduled time of 9:00 AM, as per their preference, rather than at the time ordered. In the second instance, another resident received acetaminophen later than the scheduled administration time of 7:00 AM. Both errors were confirmed through observation and staff interviews. Facility policy requires adherence to the Five Rights of Medication Administration, which include giving the right drug to the right resident, in the right amount, at the right time, and by the right route. The Director of Nursing confirmed that medications must be administered within one hour before or after the scheduled time, and deviations from this window are considered medication errors. The observed errors occurred outside of this acceptable time frame, directly contributing to the facility's medication error rate exceeding the regulatory threshold.