Medication Administration Errors Exceed Acceptable Error Rate
Penalty
Summary
Surveyors identified a medication administration deficiency in which the facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 10.71% (3 errors out of 28 opportunities) during a medication pass observation. For one resident (R30), who had multiple diagnoses including dementia, alcohol-induced persisting dementia, hypertensive heart and chronic kidney disease with heart failure, moderate protein malnutrition, Alzheimer's disease, major depressive disorder, delusional disorder, hypokalemia, and anorexia, the Medication Record for December 1–31, 2025 showed an order for phosphorus/potassium/sodium one packet by mouth four times daily at 8:00 AM, 12:00 PM, 5:00 PM, and 8:00 PM, and calcium 600 mg with vitamin D3 20 mcg daily. On December 8, 2025 at 10:34 AM, an LPN (V11) administered calcium 600 mg with vitamin D3 10 mcg instead of the ordered 20 mcg dose and also administered the resident’s 8:00 AM dose of phosphorus/potassium/sodium at 10:34 AM, outside the facility’s stated 60-minute window from the scheduled time. For another resident (R24), who had diagnoses including traumatic subdural hemorrhage, atrial fibrillation, Alzheimer's disease, anorexia, dementia, anxiety disorder, major depressive disorder, osteoarthritis, delusional disorders, and poly-osteoarthritis, the Medication Record for December 1–31, 2025 showed an order for acetaminophen 325 mg, give 650 mg by mouth three times per day at 8:00 AM, 12:00 PM, and 5:00 PM. On December 8, 2025 at 10:20 AM, the same LPN (V11) administered the resident’s 8:00 AM scheduled dose of acetaminophen, which was not given within 60 minutes of the scheduled administration time. The facility’s undated Medication Administration Policy states that medications are to be administered as prescribed, in accordance with written physician orders and good nursing principles, and within 60 minutes of the scheduled time, which was not followed in these instances.
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