Significant Medication Administration Error Due to Delayed Dosing
Penalty
Summary
A deficiency occurred when a resident with diagnoses including diabetes mellitus type 2, paranoid schizophrenia, bipolar disorder, and anxiety disorder did not receive prescribed medications as ordered. The resident was scheduled to receive Onglyza and Sitagliptin for diabetes, and Risperdal for schizophrenia, at 9:00 am. However, these medications were not administered until 10:48 am, outside the facility's policy window of one hour before or after the scheduled time. Observation showed that only lithium and benztropine were given at 8:15 am, and the remaining medications were delayed. Interviews with the LVN and DON confirmed that the medications were not administered within the required timeframe, and both acknowledged the error. The facility's policy states that medications should be given within one hour before or after the scheduled time, which was not followed in this instance. The failure to administer Onglyza, Sitagliptin, and Risperdal as prescribed constituted a significant medication error for the resident.