Medication Administration Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5 percent, as required by policy, resulting in an observed error rate of 8 percent during the survey. Observations revealed that a registered nurse (RN) handled medications with bare hands before placing them in a medication cup, contrary to facility policy, and expressed reluctance to follow the correct procedure, citing inconvenience. Additionally, the RN proceeded with a medication pass despite some prescribed medications being unavailable in the cart, and did not follow the policy for contacting the pharmacy or physician regarding the missing medications. Further observations included the RN offering medication to a resident in the hallway, during which a pill was dropped on the floor. The RN initially suggested the resident could take the dropped pill, only replacing it after surveyor intervention. The RN then discarded the dropped pill in the medication cart's trash can without following the facility's destruction policy and was unsure about the correct procedure for discarding non-opioid medications. These actions were confirmed through interviews with the RN and the Director of Nursing, who stated that the RN was familiar with facility policies.