High Medication Error Rate Due to Incorrect Dosing, Timing, and Omission
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 34.29% as observed during medication administration for three residents. Surveyors directly observed licensed nursing staff preparing and administering medications that did not match the physician orders and Medication Administration Records (MAR). Errors included administering the wrong dose of Mucinex and ferrous sulfate to one resident, and giving medications such as Senna, Nifedipine, and insulin at incorrect times to another resident. Additionally, a third resident received multiple medications at the wrong times, and a dose of furosemide was omitted entirely during the observed medication pass. Interviews with the Director of Nursing confirmed that nurses are expected to follow the facility's medication administration policy, which includes a two-hour window for timely administration and adherence to the '5 rights' of medication administration. The facility's own procedures require medications to be administered safely and effectively, with verification against the MAR at each step. Despite these policies, the observed actions of the nursing staff led to multiple medication errors involving wrong dose, wrong time, and omission of ordered medications.