Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a 27 percent error rate. This was identified through observation, interview, and record review, where 8 medication errors were found out of 29 opportunities. The errors occurred because two nurses administered medications outside of the scheduled administration times. Specifically, medications scheduled for administration at 7:00 AM or 8:00 AM were given significantly later, with times ranging from 9:04 AM to 9:58 AM. The medications involved included Levothyroxine, Acetaminophen, Diclofenac gel, Diamox, Dorzolamide-timolol, Protonix, and Hydrocortisone cream. The report details that the facility did not have a policy specifying the acceptable window for medication administration when medications were ordered at a specific time. Staff interviews confirmed that the expected practice was to administer medications within one hour before or after the scheduled time, but this was not consistently followed. The lack of adherence to scheduled medication times led to the identified errors for multiple residents, as observed and documented by surveyors.