Failure to Administer Medications Timely Due to Staffing Shortages
Penalty
Summary
Licensed Nurses failed to administer medications to residents according to physician orders, resulting in multiple instances of late medication administration for two residents. For one resident with diagnoses including palliative care and malignant neoplasm of the skin, medications such as propranolol, methadone, and gabapentin were documented as being given significantly later than scheduled, with delays ranging from over an hour to more than four hours. Another resident with epilepsy experienced late administration of medications including ropinirole, levetiracetam, and aspirin, with delays of over an hour past the scheduled times. The facility's policy allows for medications to be administered within one hour before or after the scheduled time, but these instances exceeded that window. Interviews with nursing staff and the Director of Nursing revealed that the late administration was due to severe staffing shortages, with each nurse assigned to care for 28 to 34 residents per shift. Staff reported that the high number of resident assignments made it impossible to administer all medications on time. The Director of Nursing confirmed that the facility had not met state staffing requirements during the relevant periods. One resident reported experiencing anxiety and discomfort due to the late administration of medications. The facility's own documentation and staff interviews confirmed the pattern of late medication administration and the underlying staffing issues.