Failure to Administer Medications as Ordered and Within Prescribed Timeframes
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians and within prescribed time frames, resulting in significant medication errors for three residents. For one resident, multiple medications including oxycodone, Ativan, Coreg, gabapentin, and glargine insulin were scheduled for specific times, but observation revealed that these medications were not administered within the required timeframes, and oxycodone was omitted due to unavailability. The LPN confirmed that the medications were not given as prescribed. Another resident had orders for Coreg, clonidine, erythromycin ophthalmic ointment, and prednisolone acetic ophthalmic suspension, all scheduled at specific times throughout the day. Observation showed that these medications were administered outside of the prescribed time frames, and the LPN verified the deviation from the physician's orders. A third resident, with a history of traumatic brain injury, glaucoma, and legal blindness, had orders for Rocklatan and ketorolac tromethamine ophthalmic solutions to be administered at specific times. Review of the medication administration records for two months revealed multiple missed doses and late administrations, with documentation indicating that the medications were often on order or unavailable. The RN confirmed the lack of documentation for administration on the specified dates. Facility policy required medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time, which was not followed in these cases.