Failure to Administer Critical Medications Within Prescribed Timeframe
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic respiratory failure, diabetes mellitus, hypertension, congestive heart failure, and severe cognitive impairment, did not receive prescribed medications within the required timeframe. The resident was ordered to receive hydralazine, a diuretic, three times daily and Insulin Aspart Flexpen on a sliding scale before meals and at bedtime. On the evening in question, both medications scheduled for administration at 9:00 P.M. were not given until 12:28 A.M. the following day, exceeding the facility's policy of administering medications within one hour before or after the scheduled time. The LPN assigned to the resident confirmed that the medications were not administered on time because the resident was sleeping, and there was no documentation in the medical record explaining the delay. Additionally, the physician was not notified about the late administration of these critical medications, and no entry was made to indicate the reason for the delay. The facility's policy requires documentation of medications that are refused, withheld, or not given, and mandates physician contact for critical medications like insulin if not administered as ordered. The Director of Nursing confirmed the lack of documentation and the late administration of the medications.