Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication administration observation, resulting in a 16% error rate. This was identified through record reviews, direct observation, and staff interviews. Four errors were found out of 25 medication administration opportunities, affecting two residents. The errors included missed doses, incorrect documentation, and failure to administer medications within the prescribed timeframes or according to specific instructions. For one resident with multiple diagnoses including post-surgical needs, hypertension, and anemia, the LPN prepared and administered only nine out of thirteen scheduled morning medications. Some medications, such as Vitamin E, were not available and thus not given, while others like Culturelle were administered after the surveyor left. Additionally, niacin and cefadroxil were signed as given on the MAR, but physical counts of the medication packets indicated that not all signed doses had actually been dispensed. The LPN confirmed that some medications did not appear on the MAR at the time of administration, leading to missed doses and inaccurate documentation. Another resident with complex medical conditions, including end stage renal disease and diabetes, was scheduled to receive sevelamer before meals. However, the medication was administered more than 30 minutes after breakfast, outside the prescribed timeframe, and more than one hour after the scheduled time on the MAR. The LPN acknowledged that the medication was not given as ordered, and facility policy required medications to be administered within one hour of the prescribed time or according to specific instructions such as before meals. These actions and inactions directly contributed to the facility's failure to ensure safe and accurate medication administration.