Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, resulting in a 20% error rate during observed medication passes. Specifically, staff did not adhere to proper administration protocols for ophthalmic drops, including failing to wait the required time between different eye medications and not instructing residents to apply gentle pressure to the tear duct or close their eyes after administration, as outlined in facility policy. Additionally, staff administered multiple medications in rapid succession without observing the necessary intervals between doses, and administered medications outside of the scheduled times indicated on the Medication Administration Record (MAR). Further deficiencies included administering an injectable medication for blood sugar coverage later than the physician-ordered time, without notifying the physician as required. In another instance, a staff member administered the wrong stool softener to a resident, giving a medication containing two stool softeners instead of the single stool softener that was ordered. These actions were confirmed as errors by facility leadership and staff, who acknowledged the importance of following physician orders and facility protocols to ensure correct medication administration.