Failure to Administer Medications According to Physician Orders and Care Plans
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and resident care plans for five of eight sampled residents. Staff did not administer medications as prescribed, resulting in late administration of critical medications and, in one case, a significant medication error involving a narcotic overdose. For example, one resident with epilepsy and supraventricular tachycardia did not receive seizure medication on time, as the nurse left the medications at the bedside for several hours before administration, despite the resident not being capable of self-administration and having no such order. The medication administration record did not accurately reflect the timing of administration. Another resident received a fivefold overdose of methadone when a registered nurse, distracted by another resident's needs, mistakenly administered five tablets instead of one. The error was only discovered during a subsequent narcotics count, and the nurse acknowledged the mistake. Additional residents experienced late administration of medications for blood pressure, anticoagulation, and pain management, with staff citing high resident loads, frequent interruptions, and lack of available assistance as reasons for the delays. Medication administration records showed that medications were often given hours after their scheduled times. Interviews with nursing staff and leadership confirmed that medication passes were frequently delayed due to staffing shortages and competing resident care demands. Staff reported that they were unable to administer medications within the facility's policy timeframe, and some residents noted that their medications were routinely given late, with documentation not always reflecting the actual time of administration. The facility's policy required medications to be administered within one hour of the scheduled time, but this standard was not met in multiple observed instances.