Failure to Administer Medications According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to follow physician orders and professional standards of quality in medication administration for one resident. Multiple instances were identified where medications were administered outside of the prescribed time frames. Specifically, medications such as Methylphenidate, Olanzapine, Valbenazine Tosylate, Gabapentin, and Bupropion were given significantly later than their scheduled times, with delays ranging from over an hour to several hours past the ordered administration times. These findings were confirmed through review of the Medication Administration Audit Report and interviews with both the resident and an Advanced Practice Registered Nurse. The resident involved had a diagnosis of bipolar disorder and Tardive Dyskinesia, and was prescribed several medications to be administered at specific times, including early morning and evening doses. The resident was cognitively intact, as evidenced by a Basic Interview for Mental Status (BIMS) score of 15 out of 15, and reported that medications were often given late, a statement corroborated by the audit report covering the previous 30 days. The late administration of medications included both time-critical and non-time-critical drugs, with some doses being administered several hours after the scheduled time. Facility policy required that medications be administered within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. The observed practice did not align with this policy, as numerous medications were administered well outside the acceptable window. The failure to adhere to scheduled medication times was confirmed by staff interview and documentation review, establishing a deficiency in meeting professional standards and following physician orders for medication administration.