Medication Administration Errors Due to Delayed Dosing and Lack of Documentation
Penalty
Summary
Surveyors identified that the facility failed to administer medications according to physician orders for two out of five residents observed during a medication pass, resulting in a medication error rate of 13.79% (4 errors out of 29 opportunities). Specifically, an LPN administered medications to two residents outside the scheduled administration times without documenting the delay or notifying the physician, as required by facility and pharmacy policy. The medications involved included Ferrous Sulfate and Furosemide for one resident, and Carvedilol and Furosemide for another, all of which were scheduled to be given twice daily at specific times. The residents involved had complex medical histories, including diagnoses such as heart failure, anemia, hypertension, dementia, and other chronic conditions. The LPN stated that delays occurred due to the time required to administer medications to other residents, resident preference for later administration, and a heavy workload of 30 residents. There was no documentation in the electronic medical records to account for the delayed administration or any physician notification, which is contrary to both facility and pharmacy policies that require timely administration and proper documentation of any deviations.