Medication Error Rate Exceeds 5% Due to Administration Errors and Delays
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by six medication administration errors identified out of 38 opportunities, resulting in a 15.79% error rate. For one resident with diagnoses including viral hepatitis, anxiety disorder, depression, and schizophrenia, an LPN administered Senna instead of the ordered Senna Plus during the morning medication pass. The LPN acknowledged the error after administration. Another resident with coronary artery disease, hypertension, diabetes, thyroid disorder, and depression received multiple morning medications more than one hour past the scheduled time, which the LPN confirmed was outside the facility's policy for timely administration. The LPN reported routinely finishing the morning medication pass late due to the number of residents assigned. A third resident, with orthopedic aftercare, absence of left toes, and type 2 diabetes with hyperglycemia, received sliding scale insulin after breakfast, contrary to the order for administration before meals. The LPN administering the insulin confirmed the timing was incorrect. Multiple LPNs reported to the DON that they were unable to complete medication passes within the required time frame, resulting in late administration. The DON acknowledged the late medication administrations and the associated errors during interviews, and facility policy confirmed that medications should be administered as prescribed and that deviations should be documented.