Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as evidenced by surveyor observations, record reviews, and staff interviews. Out of 31 medications observed, 3 were not administered according to provider orders or medication guidelines, and a medicated patch intended for removal was missing and unaccounted for. The issues involved multiple residents with complex medical histories, including severe cognitive impairment, diabetes, schizophrenia, and other chronic conditions. One resident with severe cognitive impairment and hypothyroidism received Levothyroxine significantly later than the ordered administration time and not on an empty stomach as required by the medication guidelines. The nurse administering the medication acknowledged the timing was incorrect but did not notify the provider, and the facility's records did not reflect any follow-up. Another resident with severe cognitive impairment was given PRN melatonin for agitation and anxiety, although the medication was only ordered for trouble sleeping at bedtime. The medication was administered several hours before the prescribed time, and there was no documentation of provider notification or follow-up regarding the resident's behavior or the off-label use of the medication. Additional deficiencies included improper insulin administration technique for a resident with diabetes, where the LPN did not follow the manufacturer's instructions for holding the insulin pen in place, and could not articulate the correct procedure. Another resident with diabetes and severe cognitive impairment received a scopolamine patch without the nurse checking for or removing the previous patch, and the missing patch was not located or documented. The nurse did not follow up with other staff or the provider regarding the missing patch, and there was no documentation in the progress notes about its loss or removal.