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F0658
D

Failure to Administer Medications Timely for Resident with GI Disorders

Holyoke, Massachusetts Survey Completed on 04-15-2025

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

Nursing staff failed to administer multiple prescribed medications to a resident with complex gastrointestinal conditions, including Parkinson's disease, ulcerative colitis, and an ileostomy, in accordance with physician orders and professional standards. The medications, which included Diphenoxylate-Atropine, Loperamide HCl, Cholestyramine, and Benefiber, were specifically ordered to be given at set times, often before meals, to manage the resident's loose stools and ileostomy output. Facility policy required medications to be administered within one hour of the prescribed time unless otherwise specified. Audit of medication administration records revealed repeated instances where these medications were given more than an hour late, and in several cases, after meals rather than before as ordered. These delays occurred on multiple dates and involved several scheduled doses, with some medications being administered up to two hours late. The late administration was confirmed by both the medication audit report and the Director of Nursing, who acknowledged that the medications were not given according to the physician's orders. The resident's representative reported that the untimely administration of these medications led to difficulties in managing the consistency and volume of the resident's ileostomy output. The facility's failure to provide timely medication administration did not meet professional standards of nursing care as outlined in facility policy and state regulations, which require nurses to implement prescribed medical regimens and adhere to accepted standards of practice.

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