Medication Error Rate Exceeded Due to Early Administration
Penalty
Summary
The facility failed to maintain a medication error rate at or below five percent during medication administration for one resident. On the observed date, a licensed vocational nurse administered five medications via gastrostomy tube to a resident with severe cognitive impairment, paraplegia, depression, and dementia. All five medications were scheduled for administration at 9 a.m., but the nurse administered them at 7:45 a.m., which was earlier than the prescribed time. The nurse acknowledged that administering medications outside the scheduled time could affect their effectiveness and that it was important to follow the correct timing to prevent medication errors. A review of the resident's records confirmed the resident's dependence on staff for all activities of daily living and the use of a feeding tube for nutrition. The facility's policy required adherence to the five rights of medication administration, including the right time. The Director of Nursing confirmed that medications should be given within one hour before or after the scheduled time and that deviations could result in medication errors. This incident resulted in five medication errors out of twenty-eight opportunities, leading to a medication error rate of 17.86%.