Failure to Administer Medications Within Prescribed Timeframes
Penalty
Summary
The facility failed to ensure that medications were administered to residents within the prescribed timeframes, as required by their own policies and federal regulations. Facility policy stated that medications should be administered within 60 minutes of the scheduled time unless otherwise ordered by a physician. Observations and interviews revealed that medications scheduled for 0900 hours were not administered on time to multiple residents. Nursing staff confirmed that they were late in administering medications due to being occupied with other residents experiencing changes in condition or needing assistance with medical appointments. Multiple residents reported that they sometimes received their medications late, and this was corroborated by direct observation of nursing staff administering medications past the scheduled times. For example, one nurse began medication administration at 0830 hours but was still administering 0900 medications to several residents after 1000 hours. Another nurse also confirmed being late with 0900 medications for several residents. Residents interviewed during the survey confirmed that they had not yet received their scheduled medications or that late administration was a recurring issue. The facility's documentation and interviews with staff indicated that the delays in medication administration were not isolated incidents but affected all 16 sampled residents. The Director of Nursing acknowledged the late administration and stated that the expectation was for medications to be given on time. The facility's failure to provide timely medication administration did not align with their established procedures and had the potential to negatively impact resident care.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 was affected by this deficient practice. Immediately, Residents' primary care provider was notified by Licensed Nurse and DON about late medication administration. All affected residents were monitored for any adverse reaction. On 6/13/2025, DON provided 1:1 education to LVN 6 about medication administration policy and procedure. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents were potentially affected by this deficient practice. On 6/24/2025, DON and Medical records audited medication administration x 1 month and found no other concern. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee the process and monitor medication administration through observation of medication administration daily for 4 weeks. From 6/24/2025, DON and ADON in-service all licensed nurses about medication administration policy and procedure and their responsibilities when they are aware that they might not meet the medication administration time-frame, including asking for help from RN supervisor or Unit Managers to make sure all residents received their medications on time. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON and designee will monitor daily medication administration x 4 weeks. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 07/9/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for three months. Corrective action completion date: 7/04/2025