Failure to Administer Medications Within Required Time Frame
Penalty
Summary
A deficiency was identified when a resident, who was not cognitively intact as indicated by a Brief Interview of Mental Status score of 0, did not receive medications within the required time frame as per physician's orders and facility policy. The resident had orders for Jardiance 10mg once daily, metoprolol tartrate 25mg twice daily, and Depakote Sprinkles 125mg (three capsules in the morning). On two separate occasions, these medications, scheduled for administration at 8:00 AM, were instead given significantly later—at 9:36 AM and 10:08 AM, respectively. The facility's policy required medications to be administered within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. During an interview, the RN acknowledged administering the medications late and stated that the resident should have been prioritized for timely medication administration. The failure to follow the prescriber's orders and the facility's medication administration policy resulted in the resident not being free from significant medication errors.