Medication Administration Delays, Errors, and Improper Techniques Identified
Penalty
Summary
Multiple deficiencies were identified related to the administration of pharmaceutical services and medication management for several residents. Residents with complex medical histories, including conditions such as atrial fibrillation, cancer, heart failure, schizophrenia, Alzheimer's, diabetes, chronic kidney disease, and depression, experienced delays in receiving their prescribed medications. Documentation showed that medications were administered significantly later than scheduled times, with some morning medications given in the evening or late at night. Residents reported that their medications were often late, and staff interviews confirmed that high resident loads and other duties contributed to these delays. Facility policy required medications to be administered within one hour of the prescribed time, which was not followed in these instances. Further review revealed that some medications were not administered at all on certain days, with no documentation to support administration for several consecutive days for one resident. In another case, a resident received double the prescribed dose of Namenda due to a medication error by an LPN. Additionally, improper medication administration techniques were observed, such as crushing extended-release tablets and mixing them with food, despite manufacturer instructions to swallow these tablets whole to avoid releasing the drug all at once. Interviews with staff, including LPNs and the Director of Nursing, verified the late administration, missed doses, and medication errors. Staff cited reasons such as high resident assignments, behavioral issues, and emergencies as contributing factors, but also acknowledged that there was enough staff present. The facility's failure to administer medications as ordered, in a timely manner, and according to proper procedures directly led to the deficiencies cited in the report.