Failure to Administer Medications Within Prescribed Timeframes
Penalty
Summary
The facility failed to ensure that medications for four out of five sampled residents were administered within one hour of their scheduled administration times, as required by the facility's policy and procedures. Specifically, multiple residents did not receive their prescribed morning medications on time, with some medications being omitted entirely on certain days. Medication Administration Records (MARs) and Administration Details Reports showed that scheduled medications, including critical drugs for conditions such as atrial fibrillation, hypertension, diabetes, and cancer, were either not given or administered several hours late. Residents affected by these delays had significant medical histories, including diagnoses such as stroke, atrial fibrillation, hypertension, diabetes mellitus, peripheral vascular disease, cancer, and chronic obstructive pulmonary disease. Interviews with residents confirmed that medications were often given late, sometimes not until several hours after the scheduled time, and in some cases, not at all. Residents expressed concern, frustration, and distress over the missed or delayed medications, emphasizing the importance of timely administration for their health conditions. Staff interviews revealed that the delays and omissions were partly due to staffing shortages, with the Director of Nursing acknowledging responsibility for ensuring coverage when licensed staff were absent. Licensed nurses and the facility pharmacist confirmed the risks associated with missed or delayed administration of medications, particularly those for blood pressure, blood thinning, and seizure control. The facility's policy clearly stated that medications must be administered within one hour of the prescribed time, and the Director of Nursing's job description included monitoring medication passes to ensure compliance.