Medication Error Rate Exceeds 5% Due to Late and Improper Administration
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5%, as required by policy and regulation. During 25 observed medication administration opportunities, five errors were identified, resulting in a 20% error rate. The errors involved two residents and included late administration of medications, improper administration technique, and lack of staff familiarity with medication protocols. Facility policy requires medications to be administered according to prescriber orders and within specified time frames, with staff expected to verify the correct resident, medication, dosage, time, and route. One resident, who had multiple diagnoses including schizoaffective disorder, anxiety, multiple sclerosis, COPD, and legal blindness, received several medications late, including ondansetron, clonazepam, gabapentin, and lansoprazole. The medication aide prepared all medications in a single cup and administered them together, failing to separate the ondansetron oral disintegrating tablet or allow it to dissolve on the tongue as required by manufacturer instructions. The aide was unaware of the proper administration method for ondansetron and was unfamiliar with the medication cart, contributing to the errors. The resident experienced gagging during administration and reported difficulty swallowing. Another resident with dementia, restlessness, and agitation was also affected by late medication administration. The LPN prepared and administered venlafaxine extended release after the designated morning window, citing unfamiliarity with the medication cart as the reason for the delay. Both staff members involved confirmed the late administration and their lack of familiarity with the assigned medication cart, which contributed to the medication errors observed during the survey.