Failure to Administer Medications as Ordered and Scheduled
Penalty
Summary
The facility failed to administer medications as ordered by physicians and as scheduled in the electronic medical record (EMR) for five residents. On a specific date, a nurse was late for her shift, resulting in a gap between the departure of the day shift nurse and the arrival of the evening shift nurse. During this period, residents did not receive their scheduled medications on time. One resident, who requires Velphoro to be taken with meals due to dialysis, did not receive the medication with dinner, and both Velphoro and Coreg were administered more than four hours after the scheduled time. The resident expressed frustration, noting that management was aware of the nurse's tardiness but did not arrange alternative coverage to ensure timely medication administration. Other residents were similarly affected by the delay. One resident had to approach the nurse to request a blood sugar check and pain medication, receiving Gabapentin almost two hours late. Another resident with moderate cognitive impairment received Gabapentin over four hours late. Additional residents with complex medical histories, including COPD, diabetes, and heart disease, also experienced delays in receiving scheduled medications such as Gabapentin and Budesonide-Formoterol Fumarate inhaler, with administration occurring up to four hours after the scheduled time. The facility's policies require that medications be administered according to physician orders and documented immediately after administration. The pharmacist confirmed that certain medications, such as Velphoro, must be given with meals for effectiveness, and significant delays in administering medications like Coreg could result in symptomatic changes. The documentation and interviews confirm that the facility did not adhere to its own policies or physician orders regarding medication administration times for multiple residents.