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F0658
D

Failure to Administer Medications Within Required Timeframe

Atlanta, Georgia Survey Completed on 04-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer scheduled medications within the required 60-minute window before or after the scheduled time for one resident. According to the facility's Medication Administration policy, medications are to be administered by licensed nurses or authorized staff as ordered by the physician and in accordance with professional standards. Record review showed that a resident with multiple diagnoses, including sepsis cystitis, urinary tract infection, depression, and dysphagia, had several medications ordered to be given at specific times in the evening. However, the Medication Administration Audit Report documented repeated instances where these medications were administered several hours past the scheduled time, with administration times ranging from over an hour to several hours late on multiple dates. The resident was noted to be cognitively intact but dependent on nursing staff for personal hygiene and was frequently incontinent. The Director of Nursing was unable to provide an explanation for the late administration of medications during an interview. Additionally, a review of the facility's Grievance Log revealed several complaints from residents regarding late receipt of medications, further supporting the finding that the facility did not consistently meet professional standards for timely medication administration.

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