Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation. During a survey, one nurse was observed making 4 medication administration errors out of 30 opportunities, resulting in a 13.33% error rate. Specifically, the nurse administered medications to a resident more than two hours after the scheduled time, despite facility policy and physician orders requiring medications to be given within one hour of the prescribed time. The medications involved included Baclofen, Depakote Sprinkles, and Furosemide, all of which were scheduled for administration at 8:00 A.M. but were given after 10:00 A.M. The resident affected had a history of cognitive communication deficit, gastroesophageal reflux disease, anemia, and anxiety. Interviews with the nurse, unit manager, and Director of Nursing confirmed that medications should be administered within one hour before or after the scheduled time, in accordance with physician orders and facility policy. The failure to adhere to these requirements led to the identified medication errors and the elevated error rate.