Medication Error Rate Exceeds 5% Due to Improper Administration and Order Discrepancies
Summary
The facility failed to maintain a medication error rate below 5%, as required, with three medication errors identified out of 25 observed opportunities, resulting in an 8% error rate. During a medication pass, a nurse administered 11 medications to a resident, including a chewable aspirin tablet and a hydrocodone-acetaminophen tablet. The resident swallowed the chewable aspirin whole instead of chewing it as ordered, and the nurse confirmed this deviation from the prescribed method. The nurse acknowledged that not chewing the medication could alter its effectiveness. Additionally, the hydrocodone-acetaminophen was administered based on outdated pain level parameters, as the medication blister pack and reconciliation count sheet did not match the updated physician order for pain management. The pharmacy had not received the updated order, and the nurse did not clarify the discrepancy with the physician. The resident involved had a history of cerebral infarction and osteomyelitis and was assessed as having moderate cognitive impairment, requiring significant assistance with daily activities. Interviews with nursing staff and the DON confirmed that medications were not administered as ordered and that discrepancies between medication orders and packaging were not addressed. Facility policy required medications to be administered according to prescriber orders, but this was not followed in the observed instances.
Plan Of Correction
F-tag 759 I: Corrective Action for residents found to have been affected: • Resident 1 order for aspirin chewable was clarified with physician by the RN on 5/28/2025. • Resident 1's pain observation/assessment was completed by RN on 5/18/2025. • A 1:1 in-service education was provided by the DON to LVN 4 regarding the Policy and Procedure on administering medication to ensure that residents received their medication per physician orders. II: Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 5/28/2025, the Medical Records Director/designee conducted a facility-wide audit of residents on aspirin chewable tablets and hydrocodone-acetaminophen orders to ensure that residents are provided medication per physician orders. • No other residents have been affected by the deficient practice. III: Measures and systemic changes put in place to ensure deficient practices do not recur: • On 05/18/2025, DON/designee conducted an in-service regarding the policy and procedure for administering medication, to licensed nurses. The goal is to ensure proper, timely, and safe administration of medication as prescribed by the physician. • The Pharmacy Nurse consultant will conduct a 3-way medication cart audit on a monthly basis for the presence of medications and accuracy of orders. Findings will be reported to the DON for follow-up. • The Medical Records Director/designee will conduct a daily audit for new physicians' orders for accuracy and will report findings to the DON during the daily stand-up meeting for follow-up. IV: Facility's plan to monitor corrective actions are achieve & sustain compliance; Integrate the POC to QA Process: • DON/designee will report issues or trends per the weekly random audits made on residents on pain management during the monthly QAA meeting x 3 months to ensure compliance. • The Pharmacy consultant will report issues or trends of monthly medication administration given by the pharmacy nurse consultant and monthly in-service educations provided regarding medication administration and review of residents on pain management. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V: Corrective Action Completion Date: 6/12/2025
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Medication error rate exceeded the 5% threshold when an RN administered two insulin doses to a resident with DM without priming the Lantus and NovoLog pens before each injection. Surveyors observed the RN give the ordered subcutaneous doses without completing the manufacturer-required safety test, and the RN stated she believed priming was only needed before first use. The DON and consultant pharmacist confirmed the pens should be primed before each dose.
Medication administration errors exceeded the allowed rate when an MA gave late doses, administered a BP medication outside ordered parameters, and gave an incorrect dose of a PPI. One resident with metabolic encephalopathy, cognitive communication deficit, and HTN received Metoprolol late, and another resident with seizures, stroke, GERD, and HTN received Levetiracetam late, Lisinopril despite BP below the hold parameter, and Pantoprazole at 20 mg instead of the ordered 30 mg.
Medication Error Rate Exceeded 5 Percent: The facility had a 7.41% medication error rate after two errors were identified. A resident ordered acetaminophen and Refresh Tears received acetaminophen and artificial tears instead of the ordered eye drops, and the CMA reported giving the meds with the morning pass and not notifying an LN that they were late. The pharmacist confirmed the eye drops and artificial tears were not the same medication, and the regional RN stated meds should be given within one hour before or after the scheduled time.
Medication Administration Error Rate Exceeded: The facility had a 7% medication error rate during observation. An LPN gave a resident sucralfate as a tablet with water instead of as a slurry 1 hour before meals, and an RN administered only one Senna Plus tablet instead of two while lidocaine patches were unavailable and on order. The resident involved in the sucralfate error had anxiety, depression, muscle weakness, and moderate cognitive impairment.
Medication administration errors exceeded the allowed rate when surveyors observed 4 errors in 27 opportunities. An LPN gave one resident's Keppra, Lexapro, and metformin late despite orders for 9 AM administration, and another LPN gave a resident's metoprolol without breakfast even though the order required it with breakfast. The DON confirmed the facility policy required medications to be given within one hour of the ordered time, and staff acknowledged the orders were not followed.
Late Administration of Scheduled Morning Medications: Surveyors found an 11.11% med error rate after an MA gave three residents their 6:30 a.m. meds well after the scheduled time. One resident with dementia and DM received metformin late and initially refused it, while two other residents with GERD or indigestion-related orders received Protonix or omeprazole late while one was sleeping and another was resting in bed. Interviews with the MA, RN, and DON confirmed late administration was considered a med error and should be reported to nursing.
Medication Error Rate Exceeded Due to Unprimed Insulin Pen Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% after surveyors identified 2 medication errors out of 30 opportunities, resulting in a 6.67% medication error rate for 1 of 3 residents observed during medication pass. The errors involved incorrect administration of insulin pens for a resident with type 2 diabetes mellitus without complications who had orders for Lantus Solostar U-100 insulin 13 units subcutaneous each morning and NovoLog FlexPen U-100 insulin 8 units before meals. During a continuous medication pass observation, Nurse #1 prepared the resident’s Lantus and NovoLog insulin pens and administered both subcutaneous doses without priming either pen as required by the manufacturer instructions. The instructions for both insulin pens stated that a safety test/priming step should be completed prior to each injection to ensure insulin comes out of the needle. In interview, Nurse #1 stated she did not know the pens should be primed before each dose and believed priming was only needed before first use. The Consultant Pharmacist stated the manufacturer instructions required priming before each dose, and the DON stated the pens should be primed prior to each dose to ensure the correct dose was administered.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. Based on observation, interview, and record review, surveyors found a medication error rate of 15.38 percent, with 4 errors out of 26 opportunities involving 2 of 3 residents reviewed for medication administration. The errors involved late administration of Metoprolol Tartrate for one resident and late administration of Levetiracetam for another resident, along with administration of Lisinopril outside ordered vital sign parameters and administration of an incorrect Pantoprazole dose. Resident #107 was a female with diagnoses including metabolic encephalopathy, cognitive communication deficit, and hypertension. Her quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment. Her physician ordered Metoprolol Tartrate 12.5 mg twice daily for hypertension, with the July 2026 MAR showing an 8:00 AM administration time. During medication administration observation, MA A gave the Metoprolol at 9:35 AM, which was after the ordered time. Resident #45 was a female with diagnoses including unspecified convulsions, cerebral infarction, GERD, and hypertension. Her annual MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Her orders included Levetiracetam 500 mg twice daily, Lisinopril 10 mg daily to be held if blood pressure was less than 100/60 or heart rate less than 55, and Pantoprazole 30 mg daily. During observation, MA A administered Levetiracetam at 9:49 AM instead of the ordered time, gave Lisinopril when the resident's blood pressure was 99/72, and administered Pantoprazole 20 mg instead of the ordered 30 mg dose.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent after two medication errors were identified, resulting in a 7.41 percent error rate. One error involved R22, whose physician orders included acetaminophen 325 mg, 2 tablets by mouth three times daily for chronic pain at 07:00 AM, 11:00 AM, and 05:00 PM, and Refresh Tears ophthalmic solution, 1 drop in both eyes three times daily for dry eye syndrome at 07:00 AM, 01:00 PM, and 08:00 PM. On 07/07/2026 at 09:03 AM, CMA R prepared R22's medications and reported that she administered the 07:00 AM medications with her other morning medications, stating she had always done it that way. She administered artificial tears, one drop in each eye, and acetaminophen at that time, and reported that she did not tell an LN that the medications were given late. Later that day, CMA R stated that R22 had always used artificial tears and did not have Refresh eye drops, and after reviewing the EMR and the label she reported the artificial tears were not the same ingredients as Refresh Tears. A medication substitution formulary had been requested the day before, but the facility did not provide one. The pharmacist reported that Refresh eye drops and the artificial tears administered were not the same medication, and both the pharmacist and the regional RN stated medications scheduled at a specific time were to be passed within one hour before or after the scheduled time. The regional RN also indicated that if a different medication was being used, the physician order would be changed.
Medication Administration Error Rate Exceeded
Penalty
Summary
The facility failed to ensure a medication error rate less than 5 percent when a medication administration observation resulted in a 7 percent error rate. Resident #42’s record showed diagnoses of anxiety, depression, and muscle weakness, with a BIMS score of 8 out of 15 indicating moderate cognitive impairment. The June 2026 MAR listed an order for sucralfate 1 gram by mouth twice daily, to be made into a slurry and given 1 hour prior to meals. During an observation, an LPN administered the sucralfate as a tablet with water instead of making it into a slurry, and the resident’s unit dinner time was listed as 5:45 p.m. while the DON stated the unit did not eat until 6:00 p.m. Resident #21’s physician orders included Senna Plus 8.6-50 mg, two tablets by mouth twice daily, and a lidocaine 4 percent patch to be applied daily at 8:00 a.m. and removed at 8:00 p.m. During a medication pass observation, an RN prepared medications for the resident but placed only one Senna Plus tablet in the pill cup and reported she was looking for lidocaine patches, which were not available because more had to be ordered from the pharmacy. The RN administered the medications without including the ordered two Senna Plus tablets, and the MAR documented a code of 9 for the lidocaine patch, with progress notes stating the patch was on order.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. Surveyors identified 4 medication errors out of 27 observed medication administration opportunities, resulting in an overall error rate of 14.81 percent for two sampled residents. The errors involved Resident 23 and Resident 2 during observed medication administration and record review. Resident 23 had diagnoses including type 2 diabetes, major depressive disorder, and epilepsy. The physician's orders showed Keppra 750 mg twice daily, Lexapro 10 mg daily, and metformin 500 mg daily, all scheduled for 9 AM. During a concurrent observation and interview, LVN 3 was preparing to administer these medications at 10:12 AM and stated they were due at 9 AM but would be given late. LVN 3 stated medications can be given one hour after they are due and that it had been over an hour since the medications were due. The DON later confirmed the facility's medication administration policy required medications to be given within one hour before or after the ordered time. Resident 2 had diagnoses including muscle weakness, hypertension, and atherosclerotic heart disease. The physician's order for metoprolol extended release 25 mg specified that it be given by mouth once daily for hypertension, hold for systolic blood pressure less than 110 and heart rate less than 60, and give with breakfast. During observation, LVN 2 administered metoprolol at 9:44 AM without breakfast or any food. LVN 2 stated she did not give the medication with breakfast and did not offer food or a snack. RN 2 and the RNS stated the medication should have been given with breakfast, and the facility policy indicated medications were to be administered following the scheduled routine unless otherwise specified by the doctor.
Late Administration of Scheduled Morning Medications
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. Surveyors found an 11.11% medication error rate, based on 3 errors out of 27 opportunities, involving three residents and one medication aide. The errors involved late administration of scheduled 6:30 a.m. medications for three residents on the same morning, and each medication was given after the scheduled time while the eMAR was marked red. Resident #69 was an older female with dementia and Type 2 diabetes with hyperglycemia. Her physician ordered Metformin HCL 500 mg twice daily for diabetes, scheduled for 6:30 a.m. and 4:30 p.m. During observation, she was in her room eating breakfast when the medication aide attempted to administer the 6:30 a.m. dose at 7:56 a.m. The aide stated the medication was scheduled for 6:30 a.m., attempted to give it using the language line, and the resident refused. The aide then notified the RN, who notified the physician. Resident #40 had diagnoses including Type 2 diabetes, cellulitis of the right lower limb, and dysphagia. She had an order for Protonix 40 mg in the morning for heartburn/indigestion, scheduled for 6:30 a.m. During observation, she was in her room sleeping with her breakfast tray untouched when the medication aide administered the dose at 8:04 a.m. Resident #38 had diagnoses including GERD and dysphagia, with an order for Omeprazole 20 mg in the morning for GERD, scheduled for 6:30 a.m. During observation, she was resting in bed when the medication aide administered the dose at 8:12 a.m. Interviews with the medication aide, RN, and DON confirmed that medications were expected to be given within an hour before or after the scheduled time, that late medications were to be reported to nursing, and that giving a medication late was considered a medication error.
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