Failure to Provide Timely Medication Administration and Adequate Personal Care
Penalty
Summary
Facility staff failed to provide timely medication administration to a resident who was admitted with multiple diagnoses, including Parkinson's disease, muscle atrophy, diabetes type 2, hypertension, and anemia. The resident was cognitively intact, able to make her own decisions, and was her own responsible party. During interviews, the resident reported receiving medications late on several occasions, sometimes hours after the scheduled time. Review of the medication administration records for March, April, and May 2025 confirmed that medications were administered later than ordered, with specific instances where medications were given up to 11 hours late. The facility's medication administration policy and the resident's care plan both required medications to be administered according to physician orders, which was not followed in these cases. Additionally, the resident was observed to be soiled and in a bed with soiled linens for an extended period during the survey, with strong odors of urine and feces present in the room. The resident reported that there were not enough staff to provide adequate care, and ADL care records indicated total dependence on staff for care. Despite documentation stating that a bath was given every morning, the resident remained soiled from morning until early afternoon and was not seen out of bed during daytime hours throughout the survey. These findings were confirmed through resident and staff interviews, clinical record review, and facility documentation.