Failure to Administer Medications at Scheduled Times Due to Staff Concerns
Penalty
Summary
The facility failed to administer medications at the scheduled times for one resident diagnosed with congestive heart failure and lymphedema. The resident had physician orders for bumetanide and potassium to be given twice daily, with scheduled administration at 7:30 AM. On two separate occasions, the morning doses were administered significantly late: on one day, both medications were given nearly three hours after the scheduled time, and on another day, the medications were administered between two hours and five minutes to over three hours late. Documentation confirmed these late administrations, and the responsible nurse signed off on the medication administration records. Interviews revealed that the nurse assigned to the resident's hallway delayed medication administration due to concerns about the resident's verbally abusive behavior. The nurse reported waiting for a nurse manager or another staff member to accompany her before administering the medications. The facility's policy requires medications to be administered within 60 minutes before or after the scheduled time, which was not followed in these instances. The Director of Nursing confirmed the facility's expectations regarding medication timing.