Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 19.35% error rate during the observed medication administration pass. Out of 31 opportunities, there were 6 medication errors involving two residents. For one resident, a LPN administered five prescribed medications, including Norvasc, Colace, Ferrous Sulfate, Levaquin, and Xarelto, significantly later than the scheduled time. The medications were due at 9:00 a.m. but were not given until 10:40 a.m., exceeding the facility's policy of administering medications within one hour of the prescribed time frame. Both the LPN and the DON confirmed the late administration during interviews. Another resident did not receive a scheduled dose of Thiamine Hydrochloride 100 mg at the prescribed 9:00 a.m. time. The LPN responsible for this medication pass failed to administer the medication, initially believing it was unavailable. However, upon further review, the medication was found on the LPN's medication cart, and the LPN acknowledged being unaware of its presence during the morning pass. These actions and inactions directly contributed to the elevated medication error rate identified during the survey.