Failure to Maintain Adequate Nursing Staff Resulting in Delayed Medication Administration
Penalty
Summary
The facility failed to maintain adequate nursing staff levels to meet the needs of residents, specifically regarding timely medication administration. On the night in question, an LPN who was scheduled to work from 6:00 P.M. to 6:00 A.M. arrived late, left the unit multiple times, and was absent from her assigned area for extended periods. Statements from staff indicated that the LPN spent significant time in her vehicle and was eventually sent home around 1:00 A.M. by another LPN, who then assumed responsibility for the unit. As a result, several residents did not receive their scheduled evening medications on time. Three residents were directly affected by the delayed medication administration. One resident with multiple chronic conditions, including multiple sclerosis, diabetes, and hypertension, did not receive several scheduled medications until after midnight, despite them being ordered for the evening. Another resident with chronic kidney disease and diabetes received insulin several hours late, and a third resident with dementia, psychosis, and anxiety received both an antihistamine and acetaminophen later than scheduled. Interviews with these residents confirmed that their medications were administered much later than expected, with some residents remaining awake until the medications were provided. The deficiency was substantiated through review of facility records, time punches, staff and resident interviews, and medication administration records. The documentation confirmed that the absence and inaction of the scheduled LPN led to a delay in medication administration for multiple residents, and that the facility did not have adequate licensed nursing staff present and available on the unit throughout the shift to meet resident needs.