Insufficient Nursing Staff Leads to Delayed and Incorrect Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely and accurate medication administration for multiple residents, as evidenced by direct observations, interviews, and record reviews. Several licensed nurses were responsible for administering medications to a high number of residents per shift, resulting in significant delays and errors. For example, one nurse was observed administering 12 medications late to a resident with epilepsy, including a seizure medication, and left the medications unattended on the bedside table for several hours. The resident was not capable of self-administering medications, and the medication administration record did not accurately reflect the times medications were given. Another incident involved a registered nurse administering a dose of methadone five times higher than ordered to a resident with acute heart failure and dementia. The nurse attributed the error to being distracted by the needs of another resident and rushing through the medication pass. The error was only discovered during a subsequent narcotics count. Additional residents experienced late administration of critical medications, such as blood pressure medications and anticoagulants, with documentation and interviews confirming that these medications were often given hours after their scheduled times. Staff interviews revealed that nurses were frequently assigned to pass medications to 25 or more residents per shift, leading to delays and increased risk of errors. Nurses reported difficulty finding assistance and being interrupted by other resident care needs, which further contributed to late medication passes. The facility's own policy required medications to be administered within one hour of the scheduled time, but this standard was not met. The Director of Nursing acknowledged that current staffing levels were insufficient to allow for safe and timely medication administration.