High Medication Error Rate Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required. During the survey, 35 medication administration opportunities were observed, resulting in 22 errors and a calculated error rate of 52.94 percent. One resident's July Medication Administration Record/Treatment Administration Record showed 18 oral medications, two nasal sprays, and one inhaled medication scheduled for administration at 07:30 AM. Observation revealed that a Certified Medication Aide administered the 07:30 AM medications at 09:52 AM, outside the one-hour window before or after the scheduled time, resulting in 18 late oral medications and one late inhaled medication; the resident declined the nasal spray. The Certified Medication Aide reported being trained by another aide who instructed that medications were only considered late after 10:00 AM. The Administrative Nurse confirmed the scheduled time and stated there was no liberalized medication pass policy in place. Facility policy requires medications to be administered at the right time, among other standards.