Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5 percent, as required. During observation of 25 medication administration opportunities, 2 errors were identified, resulting in an 8 percent error rate. One resident, admitted with pneumonia and digestive system disease, had a physician order for Zosyn IV antibiotic to be administered every eight hours at specific times. Staff G was observed administering this IV antibiotic one and a half hours late, explaining that medications were given in the order of residents down the hallway rather than by scheduled time. The Director of Nursing Services stated that facility policy required medications to be given within one hour of the scheduled time and was unaware of the late administration. Another resident, who was not cognitively impaired, was prescribed Levothyroxine for thyroid issues, which should be administered on an empty stomach 30 to 60 minutes before breakfast for optimal absorption. Staff G, an agency LPN, administered the resident's 7:00 AM dose of Levothyroxine one and a half hours late. These late administrations were directly observed and documented by surveyors, contributing to the facility's medication error rate exceeding the regulatory threshold.