Late Administration of Scheduled Medications
Penalty
Summary
Surveyors identified a deficiency in the administration of medications for two residents, as medications were not given within the required time frame according to facility policy and physician orders. During a medication pass observation, a Licensed Vocational Nurse (LVN) administered scheduled 9 AM medications to two residents after the permitted 60-minute window. The LVN confirmed that the delay occurred because they became occupied with another resident, resulting in late administration of all prescribed medications for both individuals. The first resident involved had diagnoses including neuralgia and right knee osteoarthritis, and required varying levels of assistance with daily activities. This resident was prescribed gabapentin, a multivitamin with minerals, and acetaminophen, all of which were administered late during the observed medication pass. The second resident had a medical history of hypertension, dementia, anemia, and encephalopathy, and was prescribed multiple medications including aspirin, ferrous sulfate, carvedilol, lactulose, lisinopril, and Plavix. All of these medications were also administered outside the required time frame. Interviews with facility staff, including another LVN, the Registered Nurse Supervisor, and the Director of Nursing, confirmed that medications are to be administered within one hour before or after the scheduled time, and that deviations from this protocol constitute a medication error. The Director of Nursing further stated that the LVN should have requested assistance if unable to complete the medication pass on time. Review of the facility's policy corroborated that medications must be administered in a safe and timely manner, specifically within one hour of the prescribed time unless otherwise specified.
Plan Of Correction
Immediate Corrective Action for resident affected by this deficient practice: Resident 55 and Resident 84 were reassessed by the DON on 06/11/25 and the DON also called MD for a one-time late med pass order. Plan /Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken: DON found two residents affected by the same deficient practice. Physician was notified. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur: 1:1 in-service with LVN 4 on 6/16/2025 with DON and Pharmacy Consultant with importance of timely Medication Pass emphasis to ask for assistance by another licensed nurse and call Physicians for an order to pass medications late to reduce complications. All licensed Nurses are in-serviced on 6/16/25 regarding 60 minutes Pharmaceutical/Facility Policy and Physician orders to include, "Medications must be administered within 60 minutes of scheduled time". Pharmacy Consultant to continue random twice monthly med pass observation / Medication Cart Audit per Regulation and provide DON results. Any discrepancies will be addressed immediately. See Med pass Observation form. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: Starting 7/01/25, DON or designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance. Monthly QA discussion will occur for 3 months.