Failure to Administer Medications According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one of six residents sampled for timely medication administration. Facility policy required medications to be administered in a safe and timely manner, in accordance with prescribed orders and specified time frames. However, medication administration records showed that multiple medications, including antihypertensives, laxatives, pain medications, and others, were not given within the designated medication pass times as outlined by facility policy. Instead, medications were administered outside of the prescribed time blocks, with some morning medications given late in the morning and some evening medications administered late at night. The resident involved had multiple chronic conditions, including hypertension, constipation, pain, indigestion, allergies, hormonal imbalance, gout, weight loss, dementia, and insomnia, requiring a complex medication regimen. The audit of medication administration revealed repeated instances where medications were not given at the times specified by physician orders and facility policy. The DON confirmed that medications should have been administered during the appropriate blocked times, indicating a failure to follow established protocols for medication administration.