Medication Error Rate Exceeds Acceptable Threshold Due to Timing and Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during medication administration, resulting in an observed error rate of 8%. For one resident with Type 2 Diabetes Mellitus, metformin 500 mg was not administered within one hour of the scheduled time on multiple occasions, contrary to the facility's policy and physician's order. The medication, intended to be given at 8:00 a.m. with meals, was administered as late as 10:00 a.m., and this pattern of late administration was confirmed through record review and staff interviews. The Director of Nursing confirmed that such late administration was not in accordance with facility policy and could impact the resident's care. Another resident, with diagnoses including atherosclerosis and breast cancer, was prescribed an aspirin 81 mg chewable tablet to be taken with breakfast. During a medication pass observation, the nurse did not instruct the resident to chew the tablet, and the resident swallowed it whole along with other medications. Staff interviews confirmed that the medication should have been chewed as per manufacturer instructions, and failure to do so could affect the medication's intended absorption and effectiveness. The order for the aspirin was later changed to an enteric-coated formulation, but at the time of the observation, the chewable form was in use and not administered as directed. The facility's policy on medication administration requires medications to be given within one hour of the prescribed time and according to the correct method of administration. Both deficiencies—late administration of metformin and improper administration of chewable aspirin—were observed and confirmed through interviews, record reviews, and direct observation, resulting in a medication error rate above the acceptable threshold.