Medication Administration Errors and Timing Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered by physicians and within the prescribed timeframes, resulting in a medication error rate of 36% (9 errors out of 25 administrations) during observation. For one resident, physician orders included multiple medications such as oxycodone for pain, Ativan for anxiety, Coreg for blood pressure and heart failure, gabapentin for nerve pain, and glargine insulin for diabetes. During medication administration, the LPN prepared and administered several of these medications but omitted the oxycodone due to unavailability and did not administer the remaining medications within the prescribed timeframes. The LPN confirmed these deviations from the physician's orders during an interview. Another resident had physician orders for Coreg, clonidine, erythromycin ophthalmic ointment, and prednisolone acetic ophthalmic suspension, all with specific administration times. Observation revealed that the LPN administered these medications outside of the prescribed timeframes, with some medications given significantly later than ordered. The LPN acknowledged that the medications were not administered according to the scheduled times. Facility policy requires medications to be administered safely, timely, and within one hour of the prescribed time unless otherwise specified, which was not followed in these instances.