Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications according to physician orders for five out of seven residents reviewed for medication administration. Multiple residents, all cognitively intact and with various diagnoses such as schizoaffective disorder, major depression, diabetes, hypertension, and blood clotting disorders, reported not receiving their scheduled 8:00 AM medications by late morning. Medication Administration Records confirmed that these residents were prescribed critical medications to be given at 8:00 AM, but interviews conducted between 10:48 AM and 11:24 AM revealed that none had received their morning doses. Observations further confirmed that no nurse was present on the affected hall to administer medications during this period. The delay was attributed to an agency LPN who reported being behind schedule due to managing a resident with a change of condition that required hospital transfer. The LPN acknowledged being late with medication administration and had not yet notified the physician about the delay. The facility's own policy requires medications to be administered as ordered by the physician, and staff interviews indicated that medications given more than an hour after the scheduled time are considered late. The deficiency was directly observed and corroborated by resident statements, staff interviews, and review of medical records.