Medication Availability Failures Lead to High Medication Error Rate
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered as ordered, resulting in a medication error rate of 29% during observed medication passes. On multiple occasions, staff, including an LPN and the DON, were unable to locate or obtain several prescribed medications for three residents. These medications were not available in the medication cart, Cubex machine, or overflow cart, and had been previously reordered from the pharmacy but had not yet been delivered. As a result, residents did not receive all of their prescribed morning medications. Specifically, one resident did not receive four of thirteen prescribed medications, another did not receive six of fourteen, and a third was missing at least one medication. The DON confirmed that delays in pharmacy delivery were a recurring issue, often requiring additional follow-up with the pharmacy. The observed medication administration errors involved missing essential medications such as vitamins, inhalers, patches, and other prescribed drugs, directly leading to the cited deficiency.