Late Administration of Scheduled Medications
Penalty
Summary
A deficiency was identified when a registered nurse administered a resident's scheduled 9 a.m. medications approximately one hour later than the prescribed time. The medications included aspirin, Zyprexa, vitamin D, and Keppra, which were observed being given at 10:57 a.m. The nurse confirmed that these were the resident's 9 a.m. medications and acknowledged they were administered about an hour late. The facility's policy and the Director of Nursing both stated that medications should be administered within one hour before or after the scheduled time unless otherwise ordered by a physician. The resident involved had a history of hypertension and traumatic brain injury, and required moderate assistance with certain activities of daily living, but had intact cognitive skills. The late administration of medications was observed during a medication pass, and the facility's records and staff interviews confirmed the deviation from the required medication administration schedule.
Plan Of Correction
C945: T22 DIV5 CH3 ART3-7231(a)(6) Nursing Service - Administration of Medication. Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, RN assessed Patient 2 for any adverse reactions related to the late administration of morning medications. There was no change in condition noted. On 3/10/2025, RN notified the attending physician of Patient 2 of the late administration with no new orders obtained. (To continue page 8 of 25) Identify any other residents who may have been affected by the deficient Practice. On 3/12/2025, audited the last 7 days of medication administration to ascertain if any other patients had been administered routine medications late. There were none other issues identified. Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, DSD initiated in-servicing of licensed nurses regarding the proper timing and administration of medications. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/12/2025, MRD will spot check medication administrations of 5 patients per week to ensure they are not being administered after they are due. (To continue page 9 of 25) These weekly audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25 C1115: T22 DIV5 CH3 ART3-72315(m) Nursing Service - Patient Care Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, RN placed the call light in reach of Patient 1. On 3/10/2025, RN answered the call light and attended to the needs of Patient 4. Identify any other residents who may have been affected by the deficient Practice. On 3/10/2025, ADONs and DSD made rounds of all in-house patients to ensure all call lights are in place and within reach. There were none other issues identified. On 3/10/2025, ADONs and DSD made rounds of all units to ensure staff is not walking past call lights that are engaged and ensuring that all call lights have been answered. There were none other issues identified. (To continue page 11 of 25)