Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a 17% error rate during medication administration. Out of 26 medications observed, four were administered in error. Specifically, a resident with a history of GERD, chronic pain, diabetes, and gastrointestinal issues was prescribed multiple medications with specific administration instructions, such as taking certain medications before meals, on an empty stomach, or with food. During observation, a Certified Medication Aide administered several of these medications together after the resident's breakfast, contrary to the prescribed instructions that required some to be given before meals and others with or after food. The resident also refused one medication, and another was held due to blood pressure readings. Staff interviews confirmed that the medications were not administered according to the physician's orders, with both the medication aide and a licensed nurse acknowledging the error. The nurse further verified that the resident had ongoing issues with vomiting and weight loss, and that the medications were intended to prevent these symptoms when given as ordered. The facility's policy required medications to be administered per the physician's schedule, and the error was confirmed by administrative staff, who noted that certain medications, such as Carafate, should be given separately to avoid interference with absorption.