Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below five percent, as required by regulation. During an observation, a Licensed Vocational Nurse (LVN) administered four medications—famotidine, buspirone, hydrochlorothiazide, and losartan—to a resident at a time different from what was ordered by the resident’s physician. The medications were given outside the facility’s policy window of 60 minutes before or after the scheduled administration time, which was confirmed by both the LVN and the Director of Nursing (DON) during interviews. The LVN acknowledged not following the '5 rights' of medication administration, specifically the right time, and identified these as medication errors. The resident involved had a medical history including anxiety, hypertension, and gastro-esophageal reflux disease, and was prescribed the medications for these conditions. The Medication Administration Record (MAR) and physician orders specified exact times for each medication, which were not adhered to during the observed administration. The facility’s policies and procedures clearly outlined the requirement to administer medications within a one-hour window of the prescribed time, and to verify the correct time before administration. A review of facility policies further confirmed that administering medications at the wrong time constitutes a medication error. The incident resulted in four medication errors out of 26 opportunities, leading to a medication error rate of 15.38%, which exceeds the regulatory threshold. Both the LVN and DON confirmed that the medications were not administered according to physician orders or facility policy, and these actions were classified as medication errors.