High Medication Error Rate Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, during medication administration for one of three residents observed. Specifically, during observation of 25 medication administration opportunities, 10 errors were identified, resulting in a 40% medication error rate. All of the errors involved the late administration of medications, as the medications ordered for 9:00am were instead administered at 12:05pm. The LPN responsible for the medication pass confirmed that all medications were scheduled for 9:00am, and the late administration was attributed to staffing issues. Review of the resident's Medication Administration Records showed multiple medications, including treatments for hypertension, bacterial infection, prophylaxis, supplementation, wheezing, anxiety, hyperlipidemia, nerve pain, and osteoporosis, all scheduled for the same morning time. There was no documentation that the physician was notified prior to the late administration of these medications. The facility's policy requires medications to be administered within one hour of their prescribed time unless otherwise specified, which was not followed in this instance.