F0759

E

Failure to Maintain Acceptable Medication Error Rate and Follow Medication Timing Orders

Fort Scott, Kansas Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The facility failed to maintain a medication error rate below 5 percent, with surveyors observing 30 medication administrations and identifying two errors, resulting in a 6.67 percent error rate. One identified error involved a resident whose physician orders included phenazopyridine HCL 200 mg by mouth three times a day after meals, and Protonix 40 mg delayed-release tablet to be given twice a day, 30 minutes to one hour before meals. During a morning medication pass, the certified medication aide (CMA) prepared the resident's medications but omitted the ordered phenazopyridine, stating that this medication had not been available from the pharmacy since it was ordered on the resident's admission date. The facility's policy on medication ordering and receiving from the pharmacy required timely delivery of new orders so that medication administration is not delayed and directed staff to promptly report omissions to the pharmacy and the charge nurse or supervisor.

In the same medication pass, the CMA added the prescribed Protonix 40 mg and administered it to the resident after the resident reported having just finished eating, despite the physician's order specifying that Protonix be given 30 minutes to one hour before meals. The CMA later verified that medications should be administered as ordered by the physician. The administrative nurse also confirmed that she had not been informed about the unavailability of the phenazopyridine and stated that residents should receive medications as ordered. The facility's liberalized medication administration policy specified that medications with a specified time in the order are to be scheduled at that specific time and noted that some medications must be taken before, after, or with meals, which was not followed in this instance.