F0759

D

High Medication Error Rate Due to Late Administration and Improper Alteration of ER Tablet

Racine, Wisconsin Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The facility failed to ensure the medication error rate remained below 5 percent, resulting in a calculated error rate of 30 percent (9 errors out of 30 opportunities) during a medication pass observation. Facility policy titled "Administering Medications" dated 12/2025 required medications to be administered in accordance with orders and within a 60-minute window before and after the scheduled time. During observation on the morning of 1/21/2026, a registered nurse administered tramadol 50 mg and omeprazole 40 mg to one resident at 8:27 AM, although these medications were scheduled for 7:00 AM, placing them outside the allowable administration time frame.

Later that morning, another registered nurse was observed preparing and administering multiple medications to a second resident, including atorvastatin 20 mg, Vitamin D3 200u, sertraline 50 mg, Tylenol 1000 mg, propranolol 60 mg, potassium ER 20 mEq, and Eliquis 5 mg. These medications were scheduled for 8:00 AM but were administered at 10:55 AM, again outside the facility’s defined time window. During this same pass, the nurse broke the potassium ER 20 mEq tablet in half, despite it being an extended-release formulation that is not to be broken or crushed due to its coating. The nurse reported being pulled to another unit to administer IV medications, which contributed to being behind schedule with medication administration on the unit. These observed late administrations and the improper alteration of an extended-release medication comprised the identified medication errors.