Failure to Administer Medications Within Prescribed Time Frames
Penalty
Summary
The facility failed to administer medications within the prescribed time frames as indicated by facility policy for three of four sampled residents. For one resident with a history of osteoarthritis, GERD, and thoracic spine fusion, cyclobenzaprine was scheduled for 8 AM but was administered at 9:28 AM, outside the allowed one-hour window. This resident was noted to have moderately impaired cognitive skills and required significant assistance with daily activities. Another resident, admitted with obstructive and reflux uropathy, hypertensive heart disease, and dementia, had multiple medications scheduled for administration at 8 AM and 9 AM, including bethanechol, metoprolol, verquvo, eliquis, and entresto. All these medications were administered at 10:26 AM, exceeding the facility's policy of a one-hour window before or after the scheduled time. This resident also had moderately impaired cognitive skills and required varying levels of assistance with daily living activities. A third resident with chronic kidney disease, atherosclerotic heart disease, and hypertension had orders for amlodipine and clopidogrel to be given at 9 AM, but both were administered at 10:52 AM. This resident required moderate to maximal assistance with daily care. Interviews with nursing staff and the DON confirmed the facility's policy of a one-hour administration window and the importance of timely medication administration. Review of the facility's policy and procedure corroborated these requirements.