Failure to Administer Medications as Ordered and Within Prescribed Time Frames
Penalty
Summary
The facility failed to ensure that medications were administered as ordered and within prescribed time frames, resulting in significant medication errors for three residents. Observations revealed that a registered nurse administered medications to one resident over an hour after the scheduled time, including treatments for Parkinson's disease, depression, heart failure, and hypertension. Another resident received multiple medications, such as antihypertensives, anticoagulants, antipsychotics, and vasodilators, also outside the prescribed time frames. In both cases, the nurse confirmed that the medications were not given within the required time windows as specified in the physician orders and the medication administration record (MAR). Additionally, a licensed practical nurse was observed omitting a scheduled dose of Sacubitril-Valsartan for a resident because the medication was not available at the time of administration. The nurse proceeded to administer the remaining medications and confirmed that the omitted medication needed to be reordered. Facility policy requires medications to be administered within one hour of the prescribed time unless otherwise specified, but this was not followed in the observed instances.