Failure to Administer Medications at Scheduled Times Due to Insufficient Staffing
Penalty
Summary
Surveyors identified that the facility failed to administer medications at the scheduled times for four residents reviewed for medication administration. Documentation showed repeated late administration of critical medications, including acetaminophen, carvedilol, oxycodone, trazodone, and hydromorphone. Medication Administration Records (MARs) indicated that evening medications were often given hours after the scheduled time, with some doses administered after midnight. Residents reported experiencing increased pain and disrupted sleep due to these delays, and several stated that nurses had to wake them up late at night to take their medications. Interviews with residents and staff revealed that the late administration of medications was a persistent issue, particularly during the evening shift. Residents, including the President of the Resident Council, expressed frustration and discomfort, noting that the problem had become more pronounced in recent months. Staff members, including LPNs and the wound care nurse, consistently attributed the delays to insufficient nurse staffing during the 6 PM to 10 PM shift. They reported that the facility had recently reduced the number of nurses from four to three during this critical period, making it difficult to complete medication passes on time. Facility leadership, including the Administrator and DON, acknowledged awareness of the issue, as documented in Resident Council meeting memoranda and interviews. The facility's own medication administration policy requires medications to be given within one hour of the scheduled time, but records and staff statements confirmed that this standard was not being met. The deficiency affected all residents in the facility, as the late administration of medications was not limited to the sampled residents but was reported as a widespread concern.