High Medication Error Rate Due to Omitted and Late Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying a 60% error rate during a medication administration observation involving five residents and 65 opportunities, resulting in 39 errors. The facility’s medication administration policy, revised 04/2022, required staff to compare medications with the MAR for correct resident, medication, dose, route, and time, and to administer medications within 60 minutes before or after the scheduled time unless otherwise ordered. For one resident, Hydralazine 10 mg ordered twice daily at 8:00 a.m. and 5:00 p.m. was not administered because the medication was not available in the facility and had not been ordered from the pharmacy, as confirmed by the LPN at the time of observation. For other residents, surveyors observed multiple medications being administered outside the facility’s required time frame. One resident with multiple scheduled morning medications, including Arginaid, Acetaminophen ER, Vitamin C, a multivitamin with minerals, Ferrous Gluconate, Vitamin B12, Ipratropium-Albuterol, Spironolactone, Metoprolol Succinate ER, Jardiance, and Furosemide, received these medications at 10:47 a.m., which the LPN confirmed was late given that morning medications were to be administered between 8:00 a.m. and 10:00 a.m. Additional residents with extensive 8:00 a.m. medication regimens, including antihypertensives, antiplatelets, antidepressants, vitamins, and other chronic medications, were observed receiving their morning doses after 10:00 a.m. The LPNs and the administrator confirmed that nurses were expected to administer medications within one hour before and one hour after the scheduled time, and that medications given at or after 10:00 a.m. were considered late, establishing that these administrations constituted medication errors contributing to the elevated error rate.
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