Medication Error Rate Exceeds 5% Due to Omitted Doses and Inaccurate Documentation
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy, resulting in a 13.2% error rate with 7 errors out of 53 observed opportunities. Certified Medication Technician (CMT) X was observed on one morning medication pass to have omitted several prescribed medications for two cognitively intact residents. For one resident, the omitted medications included artificial tears, Fluticasone Propionate nasal spray, Furosemide, MiraLAX, and Omeprazole. For the second resident, artificial tears and MiraLAX were not administered. Despite these omissions, the electronic Medication Administration Record (eMAR) was marked as if the medications had been given. Interviews with the residents confirmed that the omitted medications were not administered as scheduled. One resident specifically stated that the morning eye drops were not provided. CMT X later admitted during an interview that the medications, including MiraLAX for both residents, were not given due to nervousness and forgetfulness. CMT X also initially provided inaccurate information regarding the administration of eye drops and Flonase, later admitting dishonesty when questioned by surveyors and facility leadership. The facility's policy requires that medications be administered as prescribed, with accurate documentation on the MAR, and that any omissions or refusals be properly documented and communicated. In these instances, the required documentation and communication did not occur. The Regional Director of Operations confirmed that the MARs did not accurately reflect the omission or administration of medications and that the staff member involved did not follow established medication administration procedures.