Failure to Ensure Timely and Accurate Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate and timely administration of medications for two residents. For one resident with multiple diagnoses including lymphedema, cachexia, irritable bowel syndrome, and other chronic conditions, several medications—Calcium Carbonate, Diphenoxylate/Atropine, and Dicyclomine—were administered 2 hours and 45 minutes later than scheduled on a specific date. The resident reported a history of delayed medication administration, stating that this issue had persisted for two months and that he had previously complained to nursing staff about not receiving his medications before breakfast as ordered. Another resident, with a complex medical history including osteoarthritis, hypertension, diabetes, and Alzheimer's disease, did not receive her prescribed dose of Lisinopril as ordered. During a medication pass, the medication aide initially prepared only half the required dose and was about to administer it when a nurse surveyor intervened, prompting the aide to correct the dosage. The aide had only recently started working at the facility and described her training as limited to initial orientation and shadowing. Interviews with staff revealed that medication administration competency is assessed upon hire, annually, and as needed, with additional oversight from corporate and consulting pharmacists. The facility's policy requires medications to be administered safely and in a timely manner as prescribed, but observations and record reviews demonstrated that these procedures were not consistently followed, resulting in late or incorrect medication administration for the affected residents.