Medication Administration Errors and Unavailable Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered and to maintain a medication error rate below 5%, as required by regulation and facility policy. During a medication pass observation, staff made 4 errors out of 27 opportunities, resulting in a 6.75% medication error rate. The facility’s own policy required adherence to the five rights of medication administration, use of the MAR during administration, verification of orders when questions arose, and timely action when medications were unavailable, but these standards were not met in multiple instances. For one resident with diagnoses including type II diabetes mellitus, restless leg syndrome, and fibromyalgia, the physician had ordered Rosuvastatin 20 mg by mouth in the morning for hyperlipidemia and Ropinirole ER 4 mg once daily for restless leg syndrome. During observation, a CMT removed one 20 mg Rosuvastatin tablet from a plastic strip and another 20 mg tablet from a bubble pack, both labeled for that resident with the same prescription, and placed both tablets in the medication cup, administering double the ordered dose. During the same pass, the CMT was unable to locate the ordered Ropinirole ER 4 mg in the medication cart or emergency kit and informed the nurse, who stated he or she would contact the pharmacist; the medication was not available for administration as ordered. The MAR showed the Ropinirole dose previously documented as not administered with an “NA” code, but there was no corresponding nurse note explaining the reason for non‑administration. For another resident with insulin‑dependent type II diabetes and COPD, physician orders included Advair Diskus 250/50 mcg, one inhalation twice daily, and Prednisone 5 mg by mouth in the morning for COPD. During observation, a CMT could not locate the Advair Diskus inhaler and stated an intention to ensure it was ordered from the pharmacy. The same CMT reported that the 5 mg Prednisone tablet was also not available, stating the facility had ordered it and was waiting for delivery. Neither medication was available for administration as ordered during that medication pass. The MAR documented the Advair dose as not administered (“NA”) and the Prednisone dose as held (“HD”), with progress notes indicating the medications were on order. Multiple staff interviews, including CMTs, LPNs, the DON, and the Administrator, confirmed recurring issues with medication availability, delays in pharmacy delivery, inconsistent re‑ordering by CMTs, and uncertainty about nurses’ verification of physician orders, all contributing to residents not receiving ordered medications as prescribed.
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