Medication Administration Delays Due to Staffing Shortages
Penalty
Summary
A deficiency was identified in the administration of medications, where the facility failed to ensure that medications scheduled to be given more than once daily were administered at the correct times as ordered by physicians. Multiple residents across one of four units reviewed experienced significant delays or early administration of their scheduled medications. The facility's policy required medications to be administered within 60 minutes of the scheduled time, except for those tied to mealtimes, but this standard was not met for numerous residents. The report details that on a specific date, a large number of residents with various diagnoses—including chronic obstructive pulmonary disease, diabetes, heart failure, schizophrenia, hypertension, and others—did not receive their scheduled 9:00 AM medications within the required timeframe. Delays ranged from over an hour to more than four hours past the scheduled time, and in some cases, medications were administered more than an hour before the scheduled time. The affected residents had a range of cognitive abilities, from severe impairment to no impairment, as indicated by their BIMS scores. The medications involved included critical treatments such as anticoagulants, insulin, antihypertensives, and other essential therapies. The primary cause of the deficiency was a staffing shortage due to three nurse call-outs on the morning shift, which left the facility unable to find replacements. An RN who was new to the facility and had not received orientation on the unit was reassigned from her infection prevention role to perform the medication pass. She began the medication pass late and was unfamiliar with the unit, resulting in further delays. The RN communicated her concerns about the delay to the DNS, who acknowledged the situation but instructed her to continue as best as she could. The CCSO later became aware of the issue and attempted to reallocate staff, but by that time, significant delays had already occurred.