High Medication Error Rate and Untimely/Unavailable Medications During Med Pass
Penalty
Summary
Surveyors identified a medication administration deficiency when observing medication passes for two residents, resulting in 7 errors out of 25 opportunities, a 28% medication error rate. For one resident with multiple diagnoses including polycythemia vera, osteoarthritis, dysphagia, hypertension, weakness, cognitive communication deficit, atrial fibrillation, hypothyroidism, heart failure, dementia, major depressive disorder, and history of falls, the Medication Administration Record (MAR) for February showed scheduled 9:00 AM doses of cyanocobalamin 1000 mcg, hydroxyurea 500 mg two capsules, metoprolol 25 mg 1/2 tablet at 9:00 AM and 9:00 PM, Mucinex ER 600 mg at 9:00 AM and 9:00 PM, diltiazem 30 mg three times daily at 9:00 AM, 1:00 PM, and 8:00 PM, and Systane eye drops three times daily at 9:00 AM, 1:00 PM, and 9:00 PM. On the survey date at 10:36 AM, more than one hour after the scheduled time, an RN administered these medications late, gave cyanocobalamin 50 mcg instead of the ordered 1000 mcg, administered only one capsule of hydroxyurea instead of the ordered two, held the metoprolol dose despite no physician-ordered parameters to do so, administered Mucinex 400 mg instead of 600 mg, gave diltiazem over one hour late, and reported that the ordered Systane eye drops were not available. For a second resident with diagnoses including diabetes mellitus with unspecified diabetic retinopathy with macular edema, history of falls, pain, weakness, age-related nuclear cataract, macular degeneration, dry eye syndrome, and major depressive disorder, the February MAR showed an order for Preservision (multiple vitamins with minerals) one tablet by mouth twice daily at 9:00 AM and 5:00 PM related to type 2 diabetes with diabetic retinopathy with macular edema. During the survey, an RN stated that the ordered eye vitamins were not available. The Regional Nurse Consultant later stated that medications should be administered within one hour before or after the scheduled time, that late medications should be reported to the physician for possible new orders, and that medications should only be held if there are physician-ordered parameters or after consulting the physician. The consultant also stated that artificial tears and eye vitamins were believed to be facility stock medications, and if not available as stock, staff should obtain them from the pharmacy. The facility’s Medication Administration Schedule policy, approved in November 2025, states that medications shall be administered according to established schedules.
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