Medication Error Rate Exceeds 5% Due to Timing and Order Lapses
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, resulting in an observed error rate of 8.6% during the survey. For one resident with a history of venous thrombosis, embolism, and hypothyroidism, a Certified Medication Aide (CMA) administered levothyroxine and apixaban outside of the prescribed timeframes. Levothyroxine was not given 30 to 60 minutes before breakfast as ordered, and apixaban was not administered within the specified two-hour window. The CMA attributed the late administration to being assigned to two resident halls, which delayed medication delivery. The resident had already eaten breakfast before receiving the morning medications, contrary to the provider's orders and facility policy. In another instance, a different CMA administered Artificial Tears to a resident who exhibited redness and irritation around the eyes. However, the order for Artificial Tears had expired, and the medication was given without an active provider order. The CMA believed there was an active order but acknowledged that all medications require a current order before administration. The Director of Nursing confirmed that medications should not be administered without an active order and that it is the responsibility of both the CMAs and nurses to ensure orders are up to date before giving any medication.