Failure to Administer Medications Timely for Dependent Resident
Penalty
Summary
The facility failed to ensure that medications were administered in a timely manner for one resident. Specifically, a resident with moderate cognitive deficits, total dependence on staff for care, a terminal diagnosis of progressive multifocal leukoencephalopathy, a Foley catheter, and a PEG tube for feeding did not receive her scheduled morning medications until the afternoon. The Medication Administration Audit Report showed that ten morning medications, scheduled between 7 am and 9 am, were not given until 12:20 PM, and two additional medications scheduled for 11:00 AM were administered at 3:37 PM. There was no documentation in the clinical record that the physician had been notified of these late administrations. Facility policy required that morning medications be administered between 7 am and 9 am, and later morning medications between 11 am and 1 pm, with immediate documentation after administration. The failure to follow these policies was confirmed by staff interviews and record review. The resident was observed to be in bed, receiving continuous tube feeding, and unable to respond to questions at the time of observation. The lack of timely medication administration and absence of physician notification constituted the deficiency identified during the survey.