Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 7.3%. Certified medication aide (CMA) K was observed making three medication administration errors out of forty-one opportunities. These errors included not verifying a resident's physician order with the medication prescription label before administering artificial tears, failing to document the administration of a PRN (as needed) eyedrop medication, and preparing medications intended for one resident to administer to another resident. During the medication pass, CMA K did not check the prescription labels to ensure the medications were for the correct resident and was unable to describe the 'rights' of medication administration when questioned. Further interviews with nursing staff and the administrator confirmed that facility policy requires staff to compare the medication administration record (MAR) with the medication prescription label before administering medications. Staff are also expected to document all administered medications immediately in the electronic MAR (eMAR) and to contact the pharmacy or physician if discrepancies are found. The facility's policy also outlines the need to verify resident identity and ensure medications are only administered to the resident for whom they are prescribed. The observed deficiencies occurred despite the facility's written policies and procedures, which specify safe and accurate medication administration practices, including the verification of the six 'rights' of medication administration. The errors made by CMA K were directly observed by surveyors and confirmed through interviews and record reviews, demonstrating a failure to follow established protocols for medication safety and documentation.