Medication Error Rate Exceeds 5% Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, during medication administration observations. Out of 28 medication administration opportunities, there were 2 errors, resulting in a 7.14% medication error rate. Specifically, a medication aide administered metoclopramide and gabapentin to a resident 51 minutes past the prescribed administration window. The aide did not notify the charge nurse about the late administration, which was outside the facility's policy of administering medications within one hour before or after the scheduled time. The resident involved had diagnoses including diabetes mellitus with diabetic neuropathy and gastro-esophageal reflux, and was assessed as having intact cognition. The resident's care plan and physician orders specified the timing and dosage for the medications. The delay occurred because the resident was receiving a bath at the scheduled time, and the aide chose to return later without informing supervisory staff. Facility policy and interviews confirmed that this timing exceeded the acceptable administration window and constituted a medication error.