Failure to Notify Physician of Late Medication Administration
Penalty
Summary
The facility failed to notify the attending physician when medications were not administered on a timely basis as prescribed for two patients. For one patient, who had diagnoses including muscle weakness, GERD, depression, and cerebral infarction, multiple scheduled morning medications were not administered at the prescribed time. The medications, which included pregabalin, duloxetine, famotidine, fenofibrate, and several supplements, were given three and a half hours late without prior notification to the physician. The patient confirmed not receiving the medications on time, and the nurse acknowledged that the physician was not notified of the missed doses or the late administration. The subsequent dose was administered only a few hours after the late dose, again without physician input, and there was no documentation of assessment for adverse reactions due to the close timing of doses. For the second patient, who had paraplegia and was cognitively intact, the morning medications were not administered at the scheduled time due to the patient's refusal, except for pain medication. The nurse waited for the patient to request the medications and eventually administered them several hours late. The physician was only notified about the late administration after the survey team inquired, and not before the medications were given. The nurse stated that the physician should be notified in such situations to avoid potential double dosing, especially for medications scheduled twice daily. The facility's policy required contacting the physician if a dose was believed to be inappropriate or excessive, but this was not followed prior to the late administration. Interviews with nursing staff and the Director of Nursing confirmed that the facility did not have a specific policy for late medication administration, but acknowledged the importance of notifying the physician before giving late doses. The staff recognized that failing to notify the physician and document instructions could lead to inappropriate medication timing and potential adverse effects. The deficiency was identified through interviews, record reviews, and direct observation, showing a lack of timely physician notification and documentation when medications were not administered as ordered.
Plan Of Correction
C 0875 - NURSING SERVICE - GENERAL Medication Administration IMMEDIATE CORRECTIVE ACTION: 1. The RN supervisor assessed Patient 10 on any signs of adverse outcome regarding medications that were not administered on time per MD orders. Vital signs were taken and recorded as follows: BP =124/74, P = 76, R = 19, O2 Sat = 96% and Pain level = 2/10. Patient 10 was deemed stable with no issues and remained verbally responsive, alert and oriented x 4 with no apparent complaint at this time. 2. The RN supervisor assessed Patient 5 for any abnormality of vital signs: BP = 131/74, P = 80, R = 18, O2 Sat = 96% & Pain level = 0/10. Patient 5 was stable with no signs of distress and remained alert/oriented x 4, able to verbalize needs with no problem. 3. A one-on-one in-service was initiated and completed with LVN 2 and LVN 4 respectively to discuss the P/P on timely medication administration. The emphasis was to be very careful in following the guidelines for patients' health and well-being under their care. Discussed also the potential of unwanted effects from medications being administered too close of the time of the next ordered dose to be given. Reiterated in the discussion on the importance for the patients' MD be notified of circumstances that may lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring would be done to ensure patient safety, followed by accurate timely documentation. An in-service was done by the DON on 10/28/2025 on all nursing staff on how to handle patients with medications that are delayed in administration. A policy and procedure titled, "Medication Administration" was reviewed and discussed. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: All alert/oriented patients are with the potential to have set ways of taking their medications, these identified patients must be properly assessed by the RN supervisor as to the need of time adjustments on their medications to be administered. Patients with special requests or needs must be communicated to their respective MDs for proper orders to ensure ultimate safety, health and well-being of identified patients. The Medical Records Department will continue to do daily audits on both eMARs and eTARs to ensure proper charting and documentation as required. Any deviations must be reported to the DON/Designee for immediate resolutions/corrections. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: The facility had implemented a Weekly Medication Pass Audit by the DON, ADON and DSD to monitor improved performance of Charge Nurses on proper and accurate medication administration. Any noted deviations must be corrected immediately, and continued mentoring with performance improvement must be done with the specific charge nurses. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report and discuss with the QAPI/QAA committee the outcomes of Weekly Medication Administration audits including issues observed during medication pass and immediate actions done to prevent deficient practice from occurring. This will be reviewed for 3 months. E) COMPLETION DATE: 10/31/2025