Medication Omission Leads to Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all physician-ordered medications were administered to a resident, resulting in a medication error rate above 5 percent. Resident #70, admitted on 04/08/16, had multiple diagnoses including Alzheimer’s disease, diabetes mellitus with diabetic polyneuropathy, psychotic disorder with delusions, hypertension, severe protein calorie malnutrition, and muscle weakness. A quarterly MDS dated 01/29/26 documented severely impaired cognition with a BIMS score of 03. The resident’s care plan, dated 02/17/26, identified risk for alteration in mood related to anxiety, dementia, and depression, with an intervention to administer medications as ordered. Physician orders included Preservision AREDS 2 mg daily for macular degeneration, Protonix 40 mg daily for GERD, and Refresh Tears eye drops four times daily for dry eyes. On 02/23/26 at 9:05 A.M., an observation of LPN #362 preparing medications for Resident #70 showed that the LPN did not administer Preservision AREDS, Protonix, or Refresh Tears because the medications were unavailable. Concurrent interview with the LPN confirmed these medications would not be given at that time due to unavailability. Review of the February MAR showed these three medications were not administered on 02/23/26 for that reason. Based on 28 opportunities for medication administration and three omissions, the medication error rate was calculated at 10.7%. Review of the facility’s “Administering Medications” policy, last reviewed 04/28/25, stated that medications must be administered in accordance with orders, including required time frames. This deficiency was investigated under Complaint Numbers 2629125 and 1266301.
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