Failure to Administer Medications Timely and as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received medications in a timely manner as prescribed, in accordance with professional standards of practice and the resident's comprehensive care plan. The resident, who was over 65 years old and had multiple diagnoses including COPD, respiratory failure, atrial flutter, heart failure, and atrioventricular block, was cognitively intact but dependent on staff for most activities of daily living. The resident reported concerns about not receiving morning medications at the scheduled time, sometimes receiving them as late as noon, and was not informed of any changes to medication times. A review of the medication administration audit revealed that over a two-week period, the resident received a significant number of late medication doses. Specifically, 102 medications were administered late, with the majority given by one LPN. Medications such as Baclofen, Eliquis, and Gabapentin were repeatedly administered outside the prescribed time windows, sometimes several hours late. On multiple occasions, all scheduled morning medications were given more than an hour past the administration window, and in some cases, doses were given in close succession rather than at evenly spaced intervals as recommended by professional guidelines. This inconsistent timing did not support optimal therapeutic effects or consistent management of the resident's conditions. Staff interviews indicated that medication administration was delayed due to high resident acuity, staff needing to assist with care tasks, and challenges in managing the medication cart assignments. The facility had recently changed the medication administration schedule to a three-hour window to accommodate resident preferences and staff workflow, but staff were still expected to administer medications within this window. The DON was unaware of the extent of late medication administration until an audit was conducted at the request of surveyors. Additionally, there were concerns that some medications may have been administered on time but documented later, which is not consistent with professional nursing practice.