Medication Administration Errors Resulting in Error Rate Above 5%
Penalty
Summary
The deficiency involves failure to ensure medications were administered in accordance with physician orders, resulting in a medication error rate of 7.14% (2 errors out of 28 opportunities), which exceeded the 5% threshold. For one resident with hypertension related to hypertensive chronic kidney disease, a physician order dated 09/11/25 directed administration of metoprolol succinate ER 25 mg by mouth once daily, with instructions to hold the dose if systolic blood pressure was less than 100 mmHg or heart rate was less than 60 beats per minute. On 02/18/26, an RN prepared and administered this medication whole with water without obtaining the resident’s vital signs beforehand, as confirmed by the RN during interview, meaning the medication was given without verifying the hold parameters specified in the order. The second error involved an antibiotic order for cephalexin 500 mg by mouth four times daily for cellulitis for 10 days, with prescribed administration times of 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Facility policy required medications to be administered within one hour before or after the scheduled time, and a liberal medication administration policy specified that time-sensitive medications requiring equally spaced dosing, such as antibiotics given four times daily, must follow those scheduled times. On 02/18/26, an RN prepared the cephalexin capsule with other medications in applesauce and administered it at approximately 9:19 A.M., which was outside the physician-prescribed timeframe for that dose, as verified by the RN. These two observed errors, confirmed through observation, record review, and staff interview, led to a medication error rate above the acceptable limit.
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