High Medication Error Rate Due to Late and Improperly Documented Administration
Penalty
Summary
The deficiency involves the facility’s failure to administer medications at the ordered time, resulting in an 80% medication error rate during a medication pass observation. On 3/3/26 between 8:44 AM and 9:18 AM, an RN was observed checking a resident’s blood sugar and administering long-acting insulin at 9:10 AM, then retrieving 19 additional medications that had been pre-poured for the same resident. At 9:12 AM, the RN administered only Flonase nasal spray and left the remaining medications on the bedside table before exiting the room. The electronic MAR showed the resident’s medications highlighted in pink/red, indicating they were overdue, yet the RN documented them as administered and moved the medication cart further down the hall. Record review of the March 2026 MAR showed multiple medications ordered for administration at 8:00 AM, including Lantus insulin, Flonase, clonidine, buspirone, amlodipine, ferrous gluconate, Pro T Gold, glipizide, gabapentin, losartan, lorazepam, metformin, metoprolol, oxybutynin ER, terazosin, sertraline, senna-docusate, pantoprazole, polyethylene glycol, and milk of magnesia, many of which were scheduled once or twice daily. Facility staff stated that medications should be administered within one hour before or after the ordered time, and that medications turning red in the system indicate they are overdue. Staff also stated that late administration of twice-daily medications affects spacing between doses and could affect therapeutic levels. The facility’s medication administration policy requires drugs to be administered in accordance with written physician orders and established procedures, which was not followed in this instance.
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