Medication Administration Delays
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards of practice by not ensuring that a medication was administered to a resident in a timely manner as ordered by a physician. The medication in question was to be administered before meals, but it was frequently given late, as evidenced by the electronic Medication Administration Record (eMAR) for Resident #1. The report details multiple instances where the medication was administered significantly later than the scheduled times, which were supposed to be at 7:30 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m. Resident #1, who was admitted to the facility with various diagnoses, reported that their medication was often administered late, particularly in the morning. This was confirmed through interviews with the resident and staff, as well as a review of the eMAR. The resident expressed dissatisfaction with the timing of their medication administration, indicating that it had been a frequent issue over the past month. Interviews with nursing staff revealed that the facility's electronic system for medication administration involved marking medications as administered by changing the status from yellow to green in the eMAR. However, there was no documentation in the resident's progress notes indicating that the attending physician was notified of the late administration of medications. Despite the delays, there was no evidence of harm to the resident from the late administration of medications.
Plan Of Correction
Residents affected by deficient practice: The Facility failed to provide pharmaceutical services in accordance with professional standards of practice by not ensuring that a medication [R] an [R] medication, was administered to a resident, Resident #1, in a timely manner as ordered by a physician. Resident #1, MD was notified by Unit Manager and resident was assessed with [R] noted. Identify those individuals who could be affected by the deficient practice: All Residents receiving [R] have the potential to be affected. A facility-wide audit was conducted on 12/23/2024 to ensure all residents receiving [R] had appropriate orders and documentation in the Electronic Medical Records. No concerns were identified. What corrective action will be accomplished for those residents affected by the deficient practice: The Director of Nursing/designee provided education to Licensed Nurses on the policy of Medication Administration and the importance of following Physician orders, and notifying Residents attending Physician. The education was initiated on 12/23/2024 and will be ongoing. Measures or systemic changes to ensure that the deficiency will not recur: Director of Nursing or designee will audit Physician orders and Medication Administration records for three Residents receiving Sucralfate, weekly x4 weeks then monthly x 2 months. Results of the audit will be reviewed by the Director of Nursing or designee at the monthly Quality Assurance Meeting and Quarterly meeting over the duration of the audit process in the next 3 months. Based on the results of these audits a decision will be made regarding the need for continued submissions and reporting.