Failure to Revise Nursing Assignments Resulting in Delayed Medication Administration
Penalty
Summary
The administration failed to provide adequate oversight and leadership to ensure that nursing care assignments were revised in response to a change in staffing, resulting in residents not receiving nursing care and medications as ordered by their physicians. On a specific day, an agency RN who was scheduled to work the evening shift arrived late, and no arrangements were made to cover her assignment or ensure that her residents received timely care. The staffing coordinator confirmed that the nurse was assigned to care for a group of residents but was not present for the start of her shift, and no other staff were directed to absorb her responsibilities during her absence. Multiple residents reported and records confirmed that scheduled medications, including critical medications for conditions such as diabetes, hypertension, and pain management, were administered several hours late. For example, one resident did not receive his prescribed Velphoro, carvedilol, and insulin at the scheduled time with his meal, which he stated was necessary for the medications to be effective. The electronic medical records showed that these medications were administered more than four hours after the scheduled time. Other residents also experienced delays in receiving their medications, with documentation showing administration times ranging from nearly two to over four hours late. Interviews with staff and residents corroborated that there was a lack of communication and direction from management regarding coverage for the absent nurse. The administrator acknowledged awareness of the nurse's anticipated late arrival but did not provide a reason for the failure to revise assignments or instruct available staff to cover the affected residents. As a result, all residents assigned to the absent nurse experienced delays in receiving necessary nursing care and medications as ordered.