Failure to Administer Medications Timely and to Correct Residents
Penalty
Summary
The facility failed to ensure that medications were administered within the required time frame and to the correct residents, as evidenced by multiple instances of late medication administration and medication errors. Several residents reported receiving their medications late, particularly during night shifts and weekends. Medication Administration Audit Reports for multiple residents showed that medications were often given well outside the one-hour window before or after the scheduled administration time, with some doses being missed entirely or administered several hours late. In addition to late administration, there were documented cases where a resident was given another resident's medications. Specifically, one resident received evening medications intended for another resident, including melatonin, memantine, tamsulosin, and trazodone, in addition to their own prescribed medications. This error was noted in the nursing progress notes, and the affected resident reported feeling excessively sleepy and slept late the following day. The records did not clarify whether the resident who was supposed to receive those medications actually received the correct doses. The facility's policies on medication administration and medication errors require adherence to the six rights of medication administration, including the right resident and right time, and specify that medications should be administered within 60 minutes of the scheduled time. Despite these policies, the audit reports and interviews confirm that these standards were not consistently met for several residents over multiple days, resulting in both late and incorrect medication administration.