Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 12.12%. During a medication pass observation, four medication errors were identified out of 33 opportunities. Specifically, a resident with multiple diagnoses, including chronic obstructive pulmonary disease, chronic respiratory failure, atrial fibrillation, and urinary retention, did not receive four scheduled medications—apixaban, spironolactone, finasteride, and bethanechol—at the prescribed time. These medications were scheduled for administration at 9 AM but were instead given between 10:18 AM and 10:24 AM, outside the facility's policy window of one hour before or after the scheduled time. The resident in question was severely cognitively impaired and dependent on staff for all activities of daily living. The nurse administering the medications acknowledged that the medications were given late and described the potential impact of delayed administration for each medication. Facility policy required medications to be administered within a specific time frame, and the observed deviation from this policy led to the identified deficiency.