Failure to Ensure Timely and Authorized Medication Administration
Penalty
Summary
Staff failed to provide pharmaceutical services in accordance with facility policy and physician orders for two residents. For one resident with quadriplegia and a history of depression and UTIs, AM and noon medications were administered more than an hour after the scheduled times. The Medication Administration Record (MAR) and staff interviews confirmed that the medications were given late, with the noon dose administered at 2:14 PM, outside the facility's policy of administering medications within 60 minutes of the scheduled time. For another resident with peripheral vascular disease and cellulitis, staff left the resident's morning medications at the bedside for self-administration without a physician order or a completed self-administration assessment. The resident's medical record did not indicate authorization or assessment for self-administration, and the staff member confirmed leaving the medication at the bedside and acknowledged that this was not standard practice. Both incidents were observed and verified through staff interviews and record review.