Medication Administration Errors Exceeding 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 25 opportunities, resulting in a 12% error rate. Facility policy required medications to be administered according to physician orders, manufacturer specifications, and accepted professional standards, and specified that missed doses and wrong-time administrations are medication errors. For one resident with an order for torsemide 80 mg by mouth in the morning for edema, observation showed the medication was unavailable at the scheduled administration time. The medication aide stated they would notify the charge nurse to obtain the drug from the facility’s medication bank. The LPN later confirmed that torsemide 80 mg was not available in the medication bank, the pharmacy had been notified, and by the afternoon the medication had still not arrived, resulting in a missed dose, which was acknowledged as a medication error. Another resident had a physician’s order for sucralfate 1 g by mouth before meals and at bedtime. Observation showed the medication aide administered the sucralfate after the resident had already eaten lunch, and the aide confirmed it should have been given before the meal. A third resident had an order for finasteride 5 mg by mouth once daily, scheduled for 8:00 PM. Observation revealed that the medication aide administered the finasteride at 1:00 PM instead of the ordered 8:00 PM time. The DON confirmed that this medication should have been administered at 8:00 PM and that both missed doses and medications given at the wrong time are considered medication errors under facility policy.
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