Medication Administration Delay
Penalty
Summary
The facility failed to administer medications in a timely manner, resulting in a significant medication error for a resident. According to the facility's policy, medications should be administered within one hour of their prescribed time unless otherwise specified. However, on December 24, 2024, a resident received multiple medications two hours late, which was outside the timeframe indicated in the facility's policy. The medications were scheduled to be administered at 5:00 p.m., but were not given until approximately 7:11 p.m. to 7:18 p.m. The resident involved had a medical history that included heart failure, thrombocytopenia, morbid obesity, and gout. The delay in medication administration was confirmed through interviews with the resident and the facility's administrator. The administrator acknowledged that the medications were administered two hours late, which was not in compliance with the facility's policy. This incident was identified as a deficiency under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Plan Of Correction
The provider submits the following plan of correction in good faith and to comply with Federal regulation. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusion stated in the statement deficiencies. Resident physician notified on 1/13/2025 that resident received his 5pm medications 2 hours late on 12/24/2024. LPN that administered medication late on 12/24/2025 will be educated about facility medication administration policy. DON or designee will educate licensed nursing staff about Facility medication administration policy and notifying physician if medication is not administered within 2 hours as ordered by 1/24/2025. The DON/Designee will conduct random med pass observations of 5 residents per unit to ensure medications are administered timely. Audits will be done weekly x 4 weeks then monthly x 2 months. Result of medication pass audit will be presented at monthly QAPI until substantial compliance is achieved.