Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5%, as required by regulation and facility policy. During a medication pass observation, surveyors identified 11 errors out of 27 opportunities, resulting in a medication error rate of 40.74%. The errors involved two residents who did not receive their morning medications at the correct, ordered time. According to the facility's policy, medications scheduled for 7:30 AM must be administered within one hour before or after the scheduled time, specifically between 6:30 AM and 8:30 AM. One resident, with diagnoses including chronic atrial fibrillation, congestive heart failure, and type 2 diabetes mellitus, was observed receiving multiple morning medications at 8:57 AM, which was outside the permitted administration window. The medications included digoxin, furosemide, Jardiance, acetaminophen, and omeprazole, all of which were ordered for administration at 7:30 AM. The resident was cognitively intact, as indicated by a BIMS score of 15, and the medication orders were clearly documented in the EMAR. A second resident, with severe cognitive impairment and diagnoses such as atrial fibrillation, hypertension, dementia with agitation, and pruritus, was also observed receiving all scheduled 7:30 AM medications at 8:55 AM, again outside the allowed timeframe. The medications administered included digoxin, amlodipine, furosemide, losartan, quetiapine, and prednisolone, all ordered for 7:30 AM administration. The Director of Nursing confirmed that these administration times constituted medication errors according to facility policy.