Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 30% error rate during observed medication administration for four residents. Surveyors observed registered nurses and licensed practical nurses administering medications outside the physician-ordered time frames. Specifically, medications scheduled for 8:00 AM were administered between 9:31 AM and 10:03 AM, exceeding the facility's policy of administering medications within one hour before or after the scheduled time. The errors involved multiple medications, including Levetiracetam, Valproic acid, Lamotrigine, Gabapentin, Eliquis, Diltiazem, Metformin, Namenda, and Depakote, all given later than ordered. The Director of Nursing confirmed that the facility's protocol requires medications to be administered within one hour of the scheduled time and acknowledged that administration outside this window is considered a medication error. The facility's medication administration policy, dated January 2024, also specifies this timing requirement. The survey findings were based on direct observation, interviews, and review of physician orders and medication administration records, all of which confirmed that the medications were not given according to the prescribed times.