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F0684
D

Medication Administration Delays

Philadelphia, Pennsylvania Survey Completed on 01-27-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer medications in a timely manner for three residents, as evidenced by observations, policy reviews, clinical record reviews, and interviews. Resident R107 reported not receiving her 9:00 p.m. medications until after midnight and her 9:00 a.m. medications until nearly 2:00 p.m. on the following day. Her scheduled medications included treatments for depression, seizures, and blood clots. Similarly, Resident R277's medications, which included treatments for depression, allergies, pain, high blood pressure, and blood clots, were also administered late, with a delay of nearly five hours past the scheduled time. Resident R278 experienced a similar delay, with her morning medications, including treatments for fluid retention, glaucoma, high blood pressure, and steroid medication, not administered until nearly 2:00 p.m. An observation of Employee E5, a licensed nurse, revealed that she was still administering morning medications late into the morning, confirming the delay. The facility's policy requires medications to be administered within one hour of their prescribed time, which was not adhered to in these instances.

Plan Of Correction

1. Unable to retroactively correct R107, R277, R278 being administered medication late. 2. An initial was conducted of past 7 days to validate timely medication administration. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/Designee will re-educate licensed nursing staff on timeliness of medication administration. 4. DON/Designee will conduct random audits to validate medications were administered timely. This audit will be conducted 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.

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