Failure to Administer Scheduled Medications on Time
Penalty
Summary
Staff failed to administer scheduled medications on time for multiple residents, as observed and documented by surveyors. On the morning of 4/6/2025, an LPN was seen administering medications to several residents well past the scheduled 0900 time, with medication administration records (MAR) inaccurately reflecting that medications were given on time. Medication audits revealed actual administration times ranging from 10:40AM to 1:18PM, despite MAR entries indicating 0900. Residents affected included those receiving critical medications for conditions such as seizures, blood pressure, and diabetes. Two residents specifically voiced concerns about receiving their medications late, citing worries about seizure control and blood pressure management. The LPN acknowledged being behind schedule and confirmed she still had additional residents to medicate late into the medication pass. The Director of Nursing (DON) confirmed that late medication administration is unacceptable and that medications should be given within one hour of the scheduled time, as per facility policy. The DON also stated that nurses are regularly in-serviced on timely medication administration and can request assistance if running behind. Facility policy requires medications to be administered within one hour of the prescribed time unless otherwise specified by the physician.