Failure to Administer Medications Timely for Two Residents
Penalty
Summary
The facility failed to ensure timely administration of medications as ordered for two residents, resulting in multiple occurrences of late medication delivery. For one resident with severe cognitive impairment, review of the Medication Administration Record (MAR) over a 24-day period showed that scheduled 10 AM medications were repeatedly administered late, often between 11:11 AM and 12:38 PM, exceeding the facility's stated policy of administering medications within one hour before or after the scheduled time. Evening medications scheduled for 6 PM were also administered late, with times ranging from 7:28 PM to 8:43 PM. A family member reported concerns about the inconsistent timing of medication administration, and staff interviews confirmed the expectation for timely delivery was not met. Another resident, who was cognitively intact and had diagnoses including hypertension, pain, diabetes, and gastroesophageal reflux disease, did not receive scheduled morning medications, including insulin and pain medication, in a timely manner. The resident reported not receiving medications after a nurse stated she would return, and multiple observations confirmed the resident's call light remained on while she waited for assistance. Staff were observed searching for the responsible nurse, who was later found to be outside on a phone call. The resident ultimately received her medications several hours late, with pain medication administered at 11:54 AM and other scheduled medications given between 12:09 PM and 2:19 PM, well after the scheduled times. Interviews with staff, including the DON and ADON, revealed a lack of awareness regarding the nurse's absence and the delay in medication administration. The DON was not informed that the nurse would be unavailable for an extended period and was unaware that medications had not been administered to all assigned residents. The delay in medication administration was only addressed after direct intervention by other staff and surveyors, highlighting a breakdown in communication and oversight that led to the deficiency.