Medication Error Rate Exceeds 5% Due to Missed and Improperly Timed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two errors identified out of 31 opportunities during medication administration observations. For one resident, a licensed nurse was unable to administer doxycycline as ordered for bronchitis because the medication was not available at the time of administration. The nurse reported that the prescription had been extended by the provider, but the medication had not yet been received from the pharmacy, resulting in a missed dose. Facility policy requires that medications be administered as prescribed and available for administration. In another instance, a licensed nurse administered omeprazole to a resident after the resident had already consumed half of their breakfast, despite physician orders specifying that the medication should be given on an empty stomach before breakfast for gastrointestinal protection. The nurse acknowledged that the order summary on the MAR did not match the prescription label, and the MAR had not been updated to reflect the correct administration time. Facility policy requires that medications be administered at the correct time and as prescribed, with accurate reconciliation between the MAR and physician orders.