Medication Administration Errors and Timing Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician and within prescribed time frames, resulting in a medication error rate of 42.86%. During observation, a registered nurse administered medications to a resident with Parkinson's disease, depression, heart failure, hypertension, and arthritic pain outside of the prescribed time frames. The medications included Carbidopa-Levodopa, divalproex, Sacubitril-Valsartan, Hydralazine, and Tylenol, all of which had specific scheduled times that were not adhered to during administration. Additionally, another resident with hypertension, constipation, anticoagulation needs, memory impairment, and mood disorder received medications such as diltiazem, Docusil, apixaban, memantine, risperidone, and Sildenafil outside of the prescribed time frames. In a separate incident, a licensed practical nurse omitted the administration of Sacubitril-Valsartan for a resident with hypertension because the medication was not available. Staff interviews confirmed that medications were not given within the required time frames, and the facility's policy required medications to be administered within one hour of the prescribed time unless otherwise specified.