Medication Error Rate Exceeds 5% Due to Missed and Mistimed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with two medication errors identified out of 27 opportunities, resulting in a 7.41% error rate. One error involved a resident with chronic kidney disease who did not receive their prescribed ergocalciferol supplement because the medication was not available in the medication cart or anywhere in the facility at the time of administration. The nurse responsible acknowledged that medications should be ordered in advance and available for timely administration, but this did not occur, leading to the omission. Another error occurred when a different resident received their prescribed calcium with vitamin D3 supplement at a time inconsistent with the physician's order. The medication was administered outside the facility's policy-defined 60-minute window for scheduled medication times. The nurse administering the medication recognized this as a failure to follow the '5 rights' of medication administration and the facility's guidelines for medication timing. Interviews with the Director of Nursing and the involved nurses confirmed that both incidents were considered medication errors according to facility policy and procedures. The facility's policies require medications to be administered as ordered by the physician and within a specified time frame, and both errors were attributed to failures in following these established protocols. The documentation review further supported that the medications were not administered as prescribed, confirming the deficiencies.