Medication Error Rate Exceeds 5% Due to Late and Omitted Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy, resulting in a 37.04% error rate based on 27 opportunities with 10 errors. Errors included administering medications at the wrong time and omitting doses. For one resident with Parkinson's Disease, carbidopa/levodopa was scheduled for specific times but was administered late and not properly documented. Another resident had all morning medications scheduled for 6:00 AM, but these were administered late due to incorrect times in the electronic medication administration record (EMAR), which staff acknowledged had not been updated to reflect the facility's standard medication administration window. A third resident did not receive a scheduled dose of pantoprazole at the specified time because they had not yet come to the dining room for breakfast. Staff interviews confirmed awareness of the discrepancies between scheduled and actual administration times, as well as the inability to update the EMAR without pharmacy intervention. The Assistant Director of Nursing and the consulting pharmacist both acknowledged that the medications were given late according to the EMAR, and that the issue with incorrect times should have been addressed sooner. These actions and inactions led to multiple medication errors affecting at least three residents, in violation of the facility's medication error policy.