Failure to Administer Medications According to Physician Orders and Timely Manner
Penalty
Summary
Facility staff failed to administer medications according to physician orders and in a timely manner for four residents. Multiple instances were documented where medications, including pain management, anti-anxiety, anticoagulants, insulin, and other critical drugs, were given significantly later than the times specified in the physician's orders. For example, morphine sulfate, magic mouthwash, and Ativan were administered hours after the ordered times for one resident, while another resident received midodrine, enoxaparin, acetaminophen, and lidocaine patch well past the scheduled administration times. Similar delays were observed for other residents, with medications such as atorvastatin, sucralfate, lidocaine cream, and insulin glargine being administered several hours late. Observations and audit reports confirmed these late administrations, and staff interviews revealed that at least one Certified Medication Aide (CMA) was aware of running behind schedule but did not report the issue. The Director of Nursing (DON) confirmed the accuracy of the documented late medication administrations. The facility had a census of 84 residents at the time, and the deficiencies were identified through record review, observation, and staff interviews.