Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Improperly Timed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 4 errors observed out of 33 opportunities, resulting in a 12.12% error rate. One incident involved a resident with a physician's order for omeprazole oral suspension via G-tube twice daily for GERD, scheduled for administration at 9:00 AM and 9:00 PM. During a medication pass, the nurse did not administer the scheduled 9:00 AM dose because the medication was out of stock and had not been reordered or refilled in advance. The nurse acknowledged not realizing the medication was unavailable and planned to contact the provider after the omission was identified. Additional errors involved the administration of fast-acting insulins (insulin lispro and insulin aspart) to three residents with diabetes. The insulins were administered more than an hour before the residents received their meal trays, contrary to manufacturer instructions and facility expectations that such insulins be given 15–30 minutes before meals. The nurse responsible stated she administered the insulin after scheduled blood sugar checks, anticipating meal trays would arrive soon, but was unsure of the exact timing. Both the DON and the facility Administrator confirmed that insulin should not be administered until meals are imminent and that medication refills should be requested in advance to prevent missed doses.