Significant Medication Error Due to Late Administration
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Parkinson's Disease, dementia, and major depressive disorder, did not receive scheduled medications within the facility's defined time frame. The resident, who had severely impaired cognition and was under hospice care, was prescribed several medications to be administered at specific times. During a medication administration observation, an LPN was found preparing and administering the resident's 9:00 AM medications significantly later than scheduled, with the actual administration occurring at 11:05 AM. The facility's policy and staff interviews confirmed that medications are to be given within one hour before or after the scheduled time, which was not followed in this instance. The medications involved included Divalproex Sodium, Carbidopa-Levodopa, and Tramadol, all of which were administered outside the acceptable time window. The LPN acknowledged the delay, and the medication administration system indicated the late administration with a pink color code. Both the DON and the President of Clinical Practice confirmed the facility's expectations for timely medication administration, and verified that the medications were given late. This failure to administer medications within the required time frame constituted a significant medication error for the resident.