Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent, as required by policy and regulation. During a recertification survey, it was observed that one resident received their scheduled morning medications significantly late, with administration occurring at approximately 10:45 AM instead of the prescribed 9:00 AM time. The resident, who had diagnoses including congestive heart failure, COPD, and depression, was cognitively intact and able to communicate. The medications administered late included several critical prescriptions such as Albuterol, Cardizem CD, Eliquis, Lasix, Magnesium Oxide, Olanzapine, Trelegy Ellipta, Venlafaxine ER, and Aspirin. The late administration resulted in a medication error rate of 36 percent based on 25 observations. The LPN responsible for the medication pass reported being consistently late due to a heavy workload, managing 28 residents with numerous medications, and not receiving assistance despite informing Human Resources and the nurse manager. The nurse manager confirmed awareness of the issue but did not provide additional support, stating that other nurses were able to complete their medication passes on time. The nurse practitioner was not notified of the late medications as required by facility policy, and instead, the LPN documented the issue in a communication book, which was not the appropriate protocol. The Director of Nursing acknowledged ongoing problems with timely medication administration by this nurse and reiterated the facility's policy for timely administration and proper notification procedures.