Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 15.38% based on 4 errors out of 26 observed medication administration opportunities. On 06/17/2025, one resident was administered three insulin medications, including Insulin Degludec, Insulin Lispro, and a sliding scale dose of Insulin Lispro, all after the scheduled 8:00 AM time, with the resident reporting that breakfast had already been completed and the tray removed. On 06/18/2025, another resident received Baclofen for muscle spasms late, after the scheduled 12:00 PM administration time. The Director of Nursing Services confirmed that medications are expected to be administered within one hour before or after the scheduled time, and acknowledged that these medications were not given within the required timeframe.