Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a calculated error rate of 5.88%. This deficiency was identified through observation, interview, and record review, where two medication errors were found among 34 opportunities for error. Specifically, two residents did not receive their prescribed medications at the correct times as ordered by their physicians. One resident, with a history of Chronic Obstructive Pulmonary Disease (COPD) and pneumonia, did not receive a prescribed inhaler medication (Salbutamol/Albuterol) at the scheduled time of administration. The medication was due at 8:00 a.m. but was not administered until 9:30 a.m., one and a half hours late. The nurse responsible for the medication pass signed the electronic medication administration record (EMAR) as if the medication had been given on time, but later admitted to forgetting to administer the inhaler at the prescribed time. The facility's policy requires medications to be administered within one hour of the scheduled time, and the nurse acknowledged this as a medication error. Another resident, diagnosed with Dry Eye Syndrome, did not receive prescribed lubricant eye drops at the scheduled time. The eye drops were ordered to be administered at 7:00 a.m., but were not given until 9:00 a.m., two hours late. The nurse did not verify the resident's identity or allergies prior to administration, and also acknowledged the late administration as a medication error. The facility's policy and professional references reviewed confirm that late administration constitutes a medication error, and the Director of Nursing confirmed the expectation for timely medication administration according to physician orders.