F0759

E

Failure to Maintain Medication Error Rate Below 5%

Albuquerque, New Mexico Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 27 observed opportunities, resulting in an 11.11% error rate. For one resident with a physician’s order dated 10/15/25 for sacral wound care specifying cleansing with wound cleanser, patting dry, applying zinc, and then applying an optifoam dressing, an LPN instead used normal saline in place of the ordered wound cleanser during a wound care procedure on 01/08/26. In a subsequent interview, the LPN stated he could not find wound cleanser and decided to use normal saline, confirming he did not follow the physician’s order.

For another resident with a physician’s order dated 08/05/25 for Reglan 5 mg via PEG-tube four times daily for gastric motility, a CMA had pre-poured medications into cups labeled with room numbers. During observation of medication administration on 01/04/26, a surveyor accidentally touched a green oblong pill stamped “Reglan 5” in one of the cups, and the CMA, who witnessed this contact, proceeded to crush and administer the contaminated pill via PEG-tube. For a third resident with a physician’s order dated 11/04/25 for Rybelsus 7 mg by mouth once daily, to be taken 30 minutes before food or drink, an LPN administered the medication while the resident was finishing breakfast on 01/06/26. In an interview immediately afterward, the LPN stated she did not know the medication should be given 30 minutes before any food or drink.