Medication Administration Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent during a medication administration observation, resulting in a 7.41 percent error rate. On 1/13/26 at 8:16 AM, an LPN prepared seven medications for resident R110, including Senna Plus 8.6-50 mg, and administered all seven medications to the resident. Later record review at 3:43 PM showed that R110’s physician order was for Senna 8.6 mg only, not Senna Plus, meaning the resident received an additional component (docusate) that was not ordered. The facility’s Medication Administration policy dated 8/7/23 required safe and accurate preparation and administration of medications according to physician orders, including the right medication. On the same date at 8:31 AM, another LPN prepared eleven medications for resident R70, including Geri-Kot 8.6 mg, and administered all eleven medications to the resident. Subsequent reconciliation of R70’s physician orders at 3:30 PM revealed an order for Sennosides-Docusate Sodium 8.6-50 mg, while the medication given (Geri-Kot) did not contain docusate. During an interview on 1/14/26 at 8:40 AM, the DON confirmed that Senna Plus could not be given when only Senna was ordered because it also contained docusate, and that Geri-Kot could not be given when Sennosides-Docusate was ordered because it lacked docusate. These two observed medication administration errors out of 27 opportunities resulted in a medication error rate above the 5 percent threshold.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.