Medication Administration Errors Due to Unavailable Medications
Penalty
Summary
The facility failed to administer medications as ordered by physicians, resulting in four medication errors out of 41 opportunities, which equates to a 9.75% medication error rate. This deficiency affected three residents who were observed during medication administration. Specifically, one resident with diagnoses including left ventricular failure and cognitive communication deficit did not receive prescribed Potassium and Buprenorphine due to the medications not being available. Another resident with epilepsy, COPD, and anxiety disorder did not receive their ordered Zoloft, and a third resident with atherosclerotic heart disease, diabetes, and convulsions did not receive their prescribed Levetiracetam, both omissions also due to the medications not being available at the time of administration. Observations and staff interviews confirmed that the medications were omitted during the morning medication pass because they were not on hand. Review of facility policy indicated that medications should be reordered from the pharmacy at least three days before the last dose is administered to ensure availability. The failure to have these medications available and administered as ordered led directly to the cited deficiency.