Failure to Administer Medications as Ordered and Document Timely Administration
Penalty
Summary
Surveyors identified that the facility failed to administer medications to residents according to physician orders and facility policy, resulting in multiple instances of late or missed medication administration. Several residents, all cognitively intact, reported receiving their scheduled medications hours late or not at all, particularly on a specific date when staffing was insufficient. Observations and interviews confirmed that medications intended for administration at 9am were instead given between 11:29am and 12:40pm, exceeding the facility's policy of a 60-minute window before or after the scheduled time. In some cases, medications were not available, and staff had to order them from the pharmacy, further delaying administration. Documentation review revealed that medication administration records (MARs) were not consistently signed, indicating that medications were either not given or not properly documented as administered. For example, one resident's MAR showed that fourteen medications were not signed or administered during a specific shift, while another resident's MAR showed fifteen medications not signed or administered during another shift. Staff interviews confirmed that if the MAR is not signed, the medication is considered not given, which could affect resident well-being. Residents also reported that the timeliness of medication administration depended on which nurse was working and that short staffing contributed to delays. The facility's policies and job descriptions require that medications be administered as ordered by the physician and within the specified time frame, and that the MAR be signed after each medication is given. The Director of Nursing and other staff acknowledged these expectations during interviews. However, the survey findings demonstrated that these procedures were not consistently followed, leading to late or missed medication doses for multiple residents. Resident council meeting minutes and grievance forms further corroborated ongoing concerns about medication administration timeliness.