Medication Error Rate Exceeds Acceptable Threshold Due to Early Administration and Documentation Failures
Penalty
Summary
The facility failed to ensure that its medication error rate remained below five percent, as required. During a medication pass observation, a nurse administered three medications—divalproex sodium, apixaban, and olanzapine—to a resident at 7:30 a.m., which was earlier than the scheduled administration time of 9 a.m. This early administration was not within the facility's policy of administering medications within one hour of the prescribed time, and there was no documentation to justify the deviation or to indicate that the medications were given early. The nurse later documented the medications as being given at the scheduled time, rather than at the actual time of administration. The resident involved had a complex medical history, including sepsis, acute respiratory failure with hypoxia, paranoid schizoaffective disorder, seizure disorder, dementia, and hypertensive chronic kidney disease. The resident required varying levels of assistance for daily activities and had specific medication orders for the management of mood disorders and stroke prophylaxis. The nurse stated a preference to administer all morning medications at the same time for the resident's convenience, but did not follow the required process of contacting the physician to adjust medication times or documenting the early administration. Interviews with facility staff, including the Infection Preventionist, RN, and DON, confirmed that the facility's policy mandates medication administration within one hour of the scheduled time unless otherwise specified, and that any deviations must be documented with a reason. The nurse did not adhere to these policies, resulting in three medication errors out of 25 opportunities, leading to a medication error rate of 12%. This failure was directly attributed to the nurse's actions and lack of proper documentation, as well as not following established protocols for medication administration and resident care preferences.