Medication Administration Errors Exceeding Acceptable Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 26 opportunities (11.45%) during medication administration observations. For a resident admitted with constipation, a physician’s order dated 01/06/26 directed administration of 17 grams of polyethylene glycol powder by mouth once daily. On 03/24/26 at 10:00 AM, a nurse mixed the polyethylene glycol in water, brought it to the bedside, placed it on the over-bed table, and then administered other medications and a flavored liquid used to swallow pills. The nurse left the room without giving the polyethylene glycol. When questioned at 10:30 AM, the nurse acknowledged leaving the medication on the table and stated she forgot to administer it because she was nervous; the mixed medication remained on the table in the resident’s room. Another resident with constipation had a physician’s order dated 12/14/23 for polyethylene glycol, one packet by mouth every other day, dissolved in 4–6 oz of fluid. On 03/24/26 at 9:20 AM, a nurse prepared this resident’s medications, including dissolving the polyethylene glycol in water, administered the crushed medications, gave the resident one drink of the polyethylene glycol mixture, then placed the remaining mixture on the over-bed table and left the room. At 10:33 AM, when asked about this medication, the nurse stated she should not have left the drink in the room because it contained medication and that she should have ensured the resident drank all of it. A third resident, admitted with gastroesophageal reflux disease, had a physician’s order dated 03/19/26 for calcium carbonate 600 mg by mouth in the morning as a supplement. On 03/24/26 at 8:45 AM, a nurse prepared and administered calcium carbonate 1000 mg instead. Later that day, review of the medication bottle showed tablets labeled 1000 mg, and the nurse stated she did not think calcium carbonate came in 600 mg tablets and would inform the provider about the dosage.
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