Medication Error Rate Exceeds Regulatory Limit Due to Late Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below five percent, as required by federal regulations. During a survey, it was observed that a Licensed Vocational Nurse (LVN 4) administered medications late to two residents, resulting in eight medication errors out of 25 opportunities, yielding a 32% medication error rate. The late administration occurred because LVN 4 became busy with another resident and did not administer the 9 AM medications within the required one-hour window. Resident 84, who had diagnoses including neuralgia and right knee osteoarthritis, was prescribed gabapentin, a multivitamin with minerals, and acetaminophen, all scheduled for administration at 9 AM. During observation, these medications were given at 10:18 AM, outside the permitted time frame. Resident 55, with a history of hypertension, dementia, anemia, and encephalopathy, was prescribed multiple medications including aspirin, ferrous sulfate, carvedilol, lactulose, lisinopril, and Plavix, also scheduled for 9 AM. These medications were administered at 10:30 AM, again exceeding the one-hour window. Interviews with nursing staff and the Director of Nursing confirmed that medications must be administered within one hour of the scheduled time, and that failure to do so constitutes a medication error. The facility's policy also requires medications to be given in a safe and timely manner, specifically within one hour of the prescribed time unless otherwise specified. The deficiency was attributed to the nurse not seeking assistance when unable to complete medication administration on time.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice; DON Followed as a 1:1 Medication Pass with LVN 4 and gave instruction with return Demonstration. See 6/12/2025 at 6 pm form. 1:1 in-service 6/12/2025 with DON Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken; Laminated Medication Pass reminders and given to all Medication Pass Nurses. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur; DON will do Competency Medication Pass with LVN 4 every Month times 3 months to ensure efficiency and any discrepancies will be addressed immediately by DON. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.