F0759

D

Medication Error Rate Exceeded 5% Due to Omitted Laxative Medications

Ludlow, Vermont Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The facility failed to ensure the medication error rate remained below 5%, resulting in a calculated error rate of 6.45% during surveyor observations. Out of 31 medication administration opportunities, 29 medications were observed to be given and 2 were omitted, affecting 2 of 6 sampled residents. During a medication pass observation, an RN administered medications to Resident #16, stated that all medications had been given, and the MAR later showed docusate sodium (a stool softener) as administered at the same time as the other medications, although surveyors did not observe this medication being given. In a separate observation, the same process occurred with Resident #14, where the RN confirmed all medications were administered, and the MAR documented Miralax powder (a laxative solution) as given at the same time as other medications, but surveyors did not observe the Miralax being administered.

Per interview, the DON produced time-stamp reports indicating that both the docusate sodium for Resident #16 and the Miralax for Resident #14 were documented as administered concurrently with their other prescribed medications, which conflicted with surveyor observations that these medications were not actually given.