Medication Error Rate Exceeds 5% Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a medication pass, resulting in a 9.09% error rate. Specifically, a resident with diagnoses including diabetes mellitus, paranoid schizophrenia, bipolar disorder, and anxiety disorder did not receive three scheduled medications—Onglyza, Sitagliptin, and Risperdal—within the required time frame. According to the facility's policy, medications scheduled for 9:00 am should be administered within one hour before or after the scheduled time. However, these medications were administered at 10:48 am, exceeding the allowed window. The error was observed during a medication pass, where the nurse administered other medications to the resident at 8:15 am but failed to give Onglyza, Sitagliptin, and Risperdal at that time. Both the nurse and the Director of Nursing confirmed that the medications were given late and acknowledged the deviation from the facility's medication administration policy. The resident's medical records and assessments indicated moderate cognitive impairment and the need for assistance with activities of daily living, as well as ongoing use of antipsychotic and hypoglycemic medications.