Medication Error Rate Exceeds Regulatory Limit Due to Early Administration
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, as required by regulation. During observation, interview, and record review, it was found that a nurse administered five medications to a resident more than two hours before the scheduled time, resulting in a medication error rate of 45% (5 errors out of 11 opportunities). The medications involved included Gabapentin, Cyclobenzaprine, Colace, Carboxymethylcellulose Sodium ophthalmic gel, and Rosuvastatin. The nurse admitted to administering the medications early and stated that some residents preferred their medications at specific times, but did not verify the correct timing or dosage as per the physician's orders and facility policy. The resident involved had multiple diagnoses, including dry eye syndrome, constipation, hemiparesis, hemiplegia, and hyperlipidemia. The facility's policy required medications to be administered within 60 minutes before or after the scheduled time unless otherwise ordered by the physician. The nurse did not follow this policy, and the resident was unaware of the medications received or the timing of administration. Facility leadership confirmed that medications should not be administered more than two hours before the scheduled time, as this could affect medication efficacy.