Failure to Administer Medications According to Professional Standards and Prescribed Timeframes
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards and manufacturer or pharmacist directions for several residents. For one resident with diabetes, insulin aspart was administered without ensuring a meal was provided within the recommended 5-10 minutes post-injection, as observed when the resident did not receive food until over 30 minutes after administration. Another resident with multiple medication orders via G-tube had medications set up by a Certified Medication Assistant (CMA) but administered by a Registered Nurse (RN), contrary to professional standards and facility policy that require the same staff member to both set up and administer medications. Additionally, a resident prescribed levothyroxine was not consistently receiving the medication as intended; it was sometimes administered with other medications rather than by itself and not always at the scheduled time, despite pharmacist and facility expectations for it to be given separately and early in the morning. Staff interviews confirmed that the medication was not always administered according to these standards, with both night and day shift nurses involved in the inconsistency. For another resident requiring G-tube medications, multiple morning medications scheduled for 7:00 AM were observed being administered at 9:29 AM, well outside the facility's policy of administering medications within one hour before or after the scheduled time. Staff confirmed that this timing was considered late, and the facility's policy was not followed in this instance. These findings were based on direct observation, record review, and staff interviews, and affected multiple residents with complex medical needs.