Medication Administration Errors Exceeding Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during medication administration, resulting in an error rate of 18.75%. For one resident with diagnoses including hypertension, osteoarthritis, and glaucoma, a nurse administered metoprolol succinate ER more than 60 minutes after its scheduled time on multiple occasions, contrary to facility policy. Additionally, the same resident did not receive prescribed ophthalmic medications (timolol, Alphagan P, dorzolamide, and artificial tears) as ordered. The nurse documented these medications as administered, but later admitted the resident self-administered them, despite an assessment indicating the resident was unable to self-administer medications. The medications were found at the resident's bedside, and the nurse did not have all required eye drops in stock at the time of administration. Another resident with severe cognitive impairment and multiple diagnoses was prepared to receive vitamin B complex by a nurse, although the physician's order specified thiamin (vitamin B-1) only. The nurse realized the error after preparing the medication and acknowledged that administering vitamin B complex instead of thiamin would not be in accordance with the physician's order. The resident refused all medications except one, so the incorrect medication was not administered, but the preparation of the wrong medication was still identified as a deficiency. Facility policy required medications to be administered as prescribed and within 60 minutes of the scheduled time, and only by staff authorized to do so. The policy also specified that residents assessed as unable to self-administer medications should have all medications administered by nursing staff, and unauthorized medications found at bedside should be removed. These policies were not followed in the cases described, leading to the cited deficiencies.