Failure to Administer Scheduled Medications Due to Staffing Issues
Penalty
Summary
The facility failed to administer scheduled medications as ordered by physicians for seven residents on the 500 hall. These residents had various diagnoses, including major depressive disorder, generalized anxiety disorder, Alzheimer's disease, and chronic pain, and were prescribed medications such as Lorazepam, Mirtazapine, Gabapentin, Zoloft, Donepezil, and Trazodone. Review of the Medication Administration Records (MAR) for December 2024 showed that on 12/7/2024, these residents did not receive their prescribed medications at the scheduled times. The deficiency occurred due to staffing issues during the 7:00 PM to 7:00 AM shift. After 10:30 PM, only two nurses remained in the facility, and neither was willing to take responsibility for administering medications on the 500 hall after another nurse left at 11:00 PM. One nurse communicated to the Administrator that she did not feel safe taking on the additional assignment, and as a result, neither of the two remaining nurses administered medications to the 500 hall residents. The interim DON was not contacted about the staffing shortage and was unaware of the situation at the time. Interviews with staff and the Medical Director confirmed that the residents did not receive their scheduled medications due to the lack of a nurse assigned to the 500 hall. The Administrator was notified of the staffing shortage and attempted to contact additional nurses but ultimately determined there was sufficient staff present. The Medical Director was informed of the missed medication administration, and all affected residents were assessed, with no negative outcomes reported.