F0759

E

High Medication Error Rate and Inaccurate MAR Documentation During LPN Medication Pass

Olympia, Washington Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The facility failed to maintain a medication error rate below 5%, with surveyors identifying an error rate of 23.5% (8 errors out of 34 observed medication administration opportunities). Facility policy dated 01/2023 required that medications be explained to residents, administered within 60 minutes of the scheduled time, and documented immediately after administration. During an observed medication pass on 01/21/2026 by Staff G, an LPN, multiple discrepancies were noted between medications actually administered and those documented on the Medication Administration Record (MAR) and Medication Admin Audit Reports.

For Resident 15, who had spina bifida and diabetes mellitus and required supervision with ADLs, the scheduled metformin for diabetes was not administered during the observed pass, although the MAR and audit report showed metformin, Jardiance, and duloxetine as signed off as given earlier that morning. Staff G later acknowledged realizing the metformin had been missed and could not explain why it had been signed off as given. For Resident 16, who had influenza and diabetes and was dependent for ADLs, the medication abiraterone acetate, ordered as four tablets for metastatic prostate cancer, was administered as only two tablets because no additional packets were available. The shortage was not explained to the resident, and the MAR and audit report documented the dose as fully given without notation of the partial dose.

For Resident 14, with lumbar fracture and diabetes and independent in ADLs, the observed pass included several medications but omitted aspirin and torsemide, both due at 6 AM. The audit report showed multiple medications, including aspirin, signed off as given earlier, and torsemide signed off later, while Staff G stated he did not give the torsemide and did not know what happened with the aspirin, acknowledging the medications were late. Resident 1, with alcoholic cirrhosis, esophageal varices, and ADHD, reported that medications were not passed timely or at all, and during observation did not receive ordered eczema lotion or amoxicillin; documentation showed amoxicillin signed off as given earlier and the lotion documented later, with Staff G unable to locate the cream and unsure about the antibiotic. For Resident 17, with lumbar fracture and diabetes and requiring substantial assistance with ADLs, several cardiac and psychiatric medications were administered, but aspirin and glycolax were not observed to be given, despite the audit report and MAR indicating they had been administered at the scheduled time. Staff G could not explain these discrepancies and stated that medications due at 6 AM were always going to be late because of his start time.