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Based on observation, document review, and interviews, the facility failed to ensure that all medication errors were documented and reported to the facility's Quality Committee for review.

This failure created the potential for medication errors to be underreported by staff, specifically nursing staff.

Findings:

1. Facility Registered Nurse (RN) #1, was unaware how to complete documentation regarding a medical error that occurred in the facility on 07/23/13. Without questioning by surveyors, the medication error would likely have remained unreported and would not be available for review by the facility's Quality Committee.

a) Cross Reference Tag A0405- Nursing: Administration of Drugs: Staff RN #1 failed to observe the oral administration of a medication by Sample Patient #2 on 07/23/13, per facility policy, failed to inform any staff member, including the facility's pharmacy, that a dose of medication had been discarded and would result in a medication variance, and failed to complete a medication error report for review by the facility's Quality Committee.

b) On 07/24/13 at 2:54 p.m., an interview was conducted with the facility's Director of Nursing (DON), the facility's Director of Performance Improvement and Risk Management, and the company's Vice President of Nursing, to review findings regarding the medication not administered to Sample Patient #2 and the lack of documentation of this issue. The facility's DON stated all nurses, including agency nurses, receive "med variance training" and that all nurses are expected to report medication errors on specific facility forms for review. Both the DON and the Vice President of Nursing confirmed the dose of Levaquin, not observed as taken by the patient, and the discarding of the dose by the RN, constituted a medication error. Both the DON and the Vice President of Nursing confirmed RN #1 should have made a note in the patient medical record regarding the discarded dose of Levaquin and why it was discarded. The DON reviewed the medical record for Sample Patient #2 and confirmed no nursing note was found regarding this issue. When asked if medication errors were reported by nursing staff and reviewed in Quality, the Vice President and the DON confirmed this was the expectation.