Delay in Medication Administration for Resident
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of a prescribed medication for Resident R16, who was admitted with diagnoses including congestive heart failure, alcoholic polyneuropathy, and generalized anxiety disorder. On March 18, 2025, Resident R16 reported experiencing anxiety due to a personal event and stated that a physician had ordered Ativan, which was not received for three days because it was unavailable. The nursing progress note from February 11, 2025, indicated that the resident expressed emotions of grief and anxiety, prompting the physician to order Ativan 0.5 mg by mouth twice a day. However, the medication was not administered until March 14, 2025. The delay in medication administration was attributed to the pharmacy not approving the script in a timely manner, as confirmed by Employee E10, a Registered Nurse, during an interview on March 19, 2025. This failure to provide timely pharmaceutical services resulted in the resident not receiving the necessary medication to address his anxiety, as required by the facility's obligation to meet the needs of each resident through accurate acquiring, receiving, dispensing, and administering of drugs.
Plan Of Correction
1. Resident R-116 has Ativan 0.5mg available as needed for Anxiety. 2. All residents with new orders for PRN Ativan will be assessed to ensure timely acquisition and administration of prescribed medications. 3. Nurse Educator/Designee will re-educate all professional nursing staff on the policy, "Medication Orders." 4. The DON/Designee will conduct random weekly audits times 2 months to ensure residents who have new orders for PRN Ativan have the medication delivered timely from the pharmacy. 5. Audit results will be reviewed monthly by QAPI committee.