Failure to Administer and Document Medications per Physician Orders and Facility Policy
Penalty
Summary
Facility staff failed to administer medications according to physician orders and facility policy for three residents. On the day of the survey, two residents reported not receiving their scheduled morning medications by the expected time, and one resident was unsure when medications were administered. Observations confirmed that scheduled 9:00 AM medications were given to these residents between 11:43 AM and 11:56 AM, well outside the facility's guideline of administering medications within 120 minutes of the scheduled time. The Medication Administration Reports (MARs) for these residents were marked 'red,' indicating that documentation of medication administration was not completed at the time of the survey. Interviews with nursing staff and the Director of Nursing confirmed that medications are expected to be administered within one hour before or after the scheduled time and that documentation should occur immediately after administration. The nurse responsible acknowledged administering some medications two hours late due to being delayed while escorting a resident. All three residents involved were cognitively intact, as indicated by their Brief Interview of Mental Status (BIMS) scores. The facility's own Drug Administration Guidelines require timely administration and documentation, which was not followed in these instances.