Significant Medication Administration Delays Due to MAR Unavailability
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, specifically for seven out of eleven residents reviewed. On a specific morning, a Certified Medication Aide (CMA) did not administer scheduled morning medications, including antihypertensives, psychotropics, and cardiac medications, at their prescribed times. Instead, these medications, which were ordered to be given between 7:00 am and 8:00 am, were not administered until after 11:00 am. This delay was confirmed through Medication Administration Record (MAR) reviews and interviews with staff and residents. The affected residents had various diagnoses, including Alzheimer's disease, hypertension, stroke, dementia, anxiety disorder, bipolar disorder, congestive heart failure, schizophrenia, and chronic kidney disease. Many of these residents were severely cognitively impaired, as indicated by low BIMS scores, while others were cognitively intact. Interviews with residents revealed that most were unaware of the late administration or could not recall if their medications were given late. The MARs for each resident confirmed the late administration of multiple critical medications, such as amlodipine, lisinopril, metoprolol, carvedilol, hydralazine, clonidine, depakote, buspirone, quetiapine, and amiodarone. The delay in medication administration was attributed to the unavailability of the electronic MAR and physician orders due to an internet outage. The CMA reported not feeling comfortable administering medications without access to the MAR and waited until a paper copy was provided, which did not occur until after 11:00 am. The Director of Nursing (DON) and facility physicians were not notified of the delay at the time it occurred. The facility's policy on medication errors defines omissions and wrong-time administration as errors and requires prompt physician notification of significant errors, which did not happen in this instance.