Medication Error Rate Exceeds 5% Due to Improper Timing of Order Changes
Penalty
Summary
The facility failed to maintain a medication error rate below 5.00%, as evidenced by two medication errors identified during the observation of thirty medication administration opportunities. Specifically, an LPN administered nine medications to a resident, including changes to the resident's probiotic and stool softener, after receiving new orders from the provider. The LPN updated the electronic medication profile and administered the medications, but the new orders for docusate (from capsule to tablet) and for the probiotic (from lactobacillus to saccharomyces) were scheduled to begin at later times, not at the time of administration. The LPN documented the administration in the electronic record, but the timing did not align with the scheduled start of the new orders. Review of the resident's Medication Administration Record (MAR) confirmed that the previous orders for docusate and lactobacillus were discontinued just prior to the administration, and the new orders were set to begin later in the day. The DON confirmed that both medications should have been administered after the new orders became active. Facility policy requires staff to review and confirm medication orders on the MAR prior to administration, but this procedure was not followed, resulting in a medication error rate of 6.67%.