Medication Error Rate Exceeds Regulatory Threshold Due to Delayed Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5%, as required by policy and regulation. During a recertification survey, observations, record reviews, and interviews revealed that three out of four residents observed during a medication pass experienced medication administration errors, resulting in an error rate of 59.26%. Specifically, medications scheduled for administration at 9:00 AM were instead given between 10:23 AM and 10:55 AM. In one instance, a prescribed medication was not available for administration at the scheduled time. The facility's policy required medications to be administered within one hour of the prescribed time unless otherwise specified. The residents involved had various medical conditions, including epilepsy, chronic obstructive pulmonary disease, hypertension, orthopedic aftercare, anemia, atherosclerosis, schizoaffective disorder, and chronic pain syndrome. The LPN responsible for administering the medications acknowledged being aware that the medications were late but stated that it was not possible to pass all medications on time while working alone on the unit. The LPN also indicated that management staff were aware of the need for additional help. These findings were based on direct observation and interviews conducted by surveyors.