Delayed Medication Administration Resulting in Resident Distress
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering prescribed medications, including Keppra (anticonvulsant), Buprenorphine (for pain), and Buspirone (for depression and anxiety), until five hours after the scheduled administration time. The resident, a cognitively intact female with diagnoses of cerebral palsy, major depressive disorder, post-traumatic stress disorder, chronic pain, and generalized anxiety disorder, was scheduled to receive her morning medications at 8:00 AM, but they were not administered until after 12:55 PM. Record review showed that the resident’s medication administration records (MAR) reflected significant delays in the administration of all three medications. Interviews with the resident revealed that late medication administration was a frequent occurrence, causing her increased pain, anxiety, and uncontrollable leg spasms. She reported being unable to function or get out of bed and described the experience as extremely uncomfortable and distressing. Staff interviews indicated that the ADON, who was new to the facility and being trained by the DON, was responsible for the late administration on the day in question. The ADON attributed the delay to the training process and the time spent explaining medications to residents. The facility’s policy required medications to be administered within 60 minutes of the scheduled time, but this was not followed. Both nurse practitioners interviewed confirmed that such a delay could result in increased pain and anxiety for the resident, especially given her medical conditions.