Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 17.24% during medication administration for four residents. Specific errors included omitted doses, such as polyethylene glycol for one resident and a Nepro supplement for another due to unavailability. Additionally, a resident was not instructed to rinse his mouth after using an inhaler, and another resident's medications were delayed or omitted due to issues with medication availability and timing. One LPN was observed to be significantly behind schedule during the morning medication pass, with more than half of the residents on her cart still awaiting their 9:00 am medications well after the scheduled time. Interviews with nursing staff and management confirmed expectations that medications should be administered within one hour before or after the scheduled time, and that medications should be ordered in advance to prevent running out. Pharmacy records and staff interviews revealed that some medications were not available at the time of administration, despite being ordered previously, and that there was no drug shortage for the omitted medications. The combination of omitted doses, late administration, and failure to follow proper medication administration procedures contributed to the elevated medication error rate.