Failure to Administer Scheduled Medications Within Prescribed Timeframe
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the timely administration of physician-ordered medications for one resident. Specifically, the resident did not receive five of his routine, doctor-ordered medications during the scheduled 7:00 am to 9:00 am window, and instead received them at approximately 10:35 am. This was confirmed through observation, interviews, and record review, which showed that the medications were not administered within the facility's established timeframe of one hour before or after the scheduled time. The resident involved was a male with multiple complex medical conditions, including atrial fibrillation, hypertension, renal insufficiency, diabetes, aphasia, hemiplegia, malnutrition, anxiety, and a history of stroke. He was dependent on staff for all activities of daily living, used a wheelchair, and had a G-tube for medication administration. His care plan and physician orders required several medications to be administered at 8:00 am, including medications for anxiety, depression, hypertension, muscle wasting, and gastrointestinal issues. Interviews with nursing staff revealed a lack of clarity and training regarding the procedures to follow when medications are administered outside the prescribed timeframe. Staff members were unsure of the exact steps to take if medications were given late and had not received recent training on this issue. The Director of Nursing and the Administrator both acknowledged that medications should be given within the specified window and that staff should notify supervisors if unable to do so, but there was no evidence that this protocol was followed in this instance.