Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, resulting in a medication error rate of 48.15% during a medication pass audit. Surveyors observed that 13 out of 27 medications for four residents were not administered within the required time frame. Specifically, medications scheduled for administration at 9:00 AM, 8:00 AM, and 6:00 AM were instead given significantly later, with some being administered more than an hour past the scheduled time. The medications involved included treatments for end-of-life comfort, dry eyes, dysphagia, hypertension, Parkinson's disease, chronic pain, and antibiotic therapy for infection. Staff interviews and record reviews confirmed that the facility's expectation was for medications to be administered within one hour before or after the scheduled time as listed on the Medication Administration Record (MAR). However, observations showed that this standard was not met for multiple residents, as medications were prepared and administered outside of the required time window. This failure to adhere to scheduled medication administration times constituted a deficiency under the cited regulation.