Delayed Medication Administration Due to Staffing Changes
Penalty
Summary
The facility failed to administer prescribed medications to residents in a timely manner according to physician orders, affecting 29 out of 35 sampled residents. On the day of the survey, only one nurse was assigned to each of the third and fourth floors, whereas previously two nurses had been assigned per floor. Both nurses reported that the new staffing schedule made it difficult to complete the morning medication pass within the required time frame. The eMAR system showed multiple residents with overdue medications, indicated by a red color, and both nurses confirmed that some medications were late. Observations by the surveyor confirmed that numerous residents' eMARs were marked as late, and a medication audit report documented that scheduled medications for these residents were administered outside the facility's policy window of one hour before or after the scheduled time. Facility policies require medications to be administered according to prescriber orders and within the specified time window, but these requirements were not met due to the staffing changes and resulting delays.