Failure to Ensure Timely Medication Administration and Administrative Oversight
Penalty
Summary
The facility failed to administer its resources effectively and did not provide adequate administrative oversight to ensure staff compliance with medication administration and resident care. Specifically, the facility did not maintain compliance with a previously established plan of correction related to medication administration errors. There were repeated failures to ensure that scheduled anxiety and narcotic pain medications were administered as ordered, that medications were refilled before supplies were exhausted, and that medications were delivered to the facility in a timely manner. Additionally, the facility did not ensure that the Advanced Practice Registered Nurse (APRN) was notified of medication omissions, annual performance evaluations were completed as required, or that clinical records were complete and accurate. Survey findings revealed that significant medication errors persisted, including late administration of medications and lack of notification to nursing supervisors or providers when medications were missed or delayed. Interviews with facility leadership confirmed that, despite previous citations and corrective plans, the facility had not returned to compliance and lacked a process for effective administrative oversight to address these ongoing issues. The deficiencies were identified as immediate jeopardy and substandard care in the area of pharmacy services, specifically regarding residents being free of significant medication errors.