Failure to Administer Medications on Time and Notify Physician
Penalty
Summary
A deficiency occurred when a resident did not receive their scheduled 9 a.m. medications within the required timeframe. The medications, which included Pregabalin, Duloxetine, Famotidine, Fenofibrate, and several others, were not administered within one hour of the prescribed time as required by regulation and facility policy. The delay was confirmed during a medication area inspection and through interviews with nursing staff, who acknowledged that the medications were not given as ordered and that there was no documentation of administration on the Medication Administration Record (MAR) within the required window. Further review revealed that the resident had not received any of their scheduled morning medications by the time of the inspection, and the medications were ultimately administered at 12:29 p.m., more than three hours after the scheduled time. The resident confirmed in an interview that she had not received her morning medications and stated that she does not refuse medication when woken up. Nursing staff also confirmed that the physician was not notified of the missed doses, and no reason for the omission was documented in the resident's records. Additionally, the administration of the next scheduled doses occurred at 4:10 p.m., resulting in two sets of medications being given in close succession. There was no documentation that the resident was monitored or assessed for adverse reactions following the late administration of multiple medications, including anti-constipation and seizure medications. The facility's policy requires medications to be administered within one hour of the prescribed time, and the failure to do so, along with the lack of physician notification and monitoring, constituted the deficiency.
Plan Of Correction
C 0945 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/7/2025, the RN supervisor immediately assessed Patient 10 for 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. MD and responsible party were notified. 2. On 10/7/2025, DON completed a one-on-one in-service with LVN 2 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. DON also discussed the importance of "pour, pass, sign." DON reiterated that MD be notified of circumstances that 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. C) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, upon identification of deficient practice, DON, ADON, and RN Supervisor immediately interviewed all other charge nurses regarding any other medication administration delays that took place that day. No additional delays were identified, and no other residents were identified as being affected. MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: An in-service was completed by the DON on 10/28/2025 for all nursing staff on "Medication Administration" policy and procedures. The facility had implemented a Medication Pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor improved performance of Charge Nurses on proper and accurate medication administration. Any noted deviations will be corrected immediately, and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report weekly audit findings to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C 0965 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 4. On 10/07/2025, RN Supervisor immediately assessed patient 2 for any change of condition or abnormality of wounds - no redness, no discharge observed from affected sights (right thigh scab, right pleur x site, and spine suture site). MD was notified. LVN 4, who