Medication Administration Errors Exceed Acceptable Rate Due to Late Dosing
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders, resulting in a medication error rate of 14 percent, which exceeds the acceptable threshold of 5 percent. During observation, 41 opportunities for medication administration were reviewed, and six errors were identified, affecting four residents. The errors primarily involved the late administration of scheduled medications, with morning medications being given well past the facility's established administration window of 7:00 A.M. to 11:00 A.M. For one resident with chronic obstructive pulmonary disease, hypertension, dementia, and adjustment disorder, morning medications including levetiracetam and memantine, both scheduled twice daily, were administered late at 11:23 A.M. instead of within the scheduled window. The LPN responsible confirmed the late administration, and the resident also reported that medications were usually given earlier. Another resident with neurogenic bowel, anxiety disorder, and iron deficiency anemia did not receive morning medications until 12:01 P.M., resulting in a late dose of gabapentin, which was scheduled three times daily. The LPN again verified the late administration. Additional residents were affected by similar issues. One resident with diabetes, congestive heart failure, hypertension, atrial fibrillation, and depressive disorder received Depakote, scheduled twice daily, late at 12:15 P.M. Another resident with chronic obstructive pulmonary disease, asthma, atrial fibrillation, hyperlipidemia, and depression received Apixaban and Dulera, both scheduled twice daily, late at 12:42 P.M., and Furosemide was not administered until 2:51 P.M. The LPN acknowledged the late administration and indicated that this had been an ongoing problem. The Director of Nursing confirmed the late medication passes and noted that the LPN had previously reported difficulties completing medication passes on time.