Medication Error Rate Exceeds 5% Due to Untimely and Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by regulation, with a documented error rate of 12%. For one resident, medications were not administered in a timely manner or as ordered by the physician. Specifically, a resident with multiple chronic conditions, including neuropathy and diabetes, did not receive their scheduled morning medications until several hours late. The 8:00 a.m. dose of gabapentin was not given until 12:31 p.m., and other medications such as metformin and a lidocaine patch were also administered significantly later than prescribed. There was no evidence that the physician was notified of these delays or that there were orders permitting the altered administration times. Additionally, during medication administration observation, a registered nurse was found preparing to crush medications for another resident that should not be crushed, including Metoprolol Succinate ER, Finasteride, and Clopidogrel Bisulfate. Crushing these medications can alter their effectiveness and safety, as confirmed by literature and the nurse at the time of observation. These actions were in direct violation of the facility's own medication administration policy, which requires medications to be given safely, timely, and as prescribed.