Failure to Administer Medications in a Timely Manner
Penalty
Summary
The facility failed to follow its Medication Administration Policy by not administering medications in a timely manner to four residents. Observations revealed that multiple nurses were delayed in passing morning medications, with some residents receiving their scheduled 8:00 AM medications as late as 10:30 AM. Staff interviews confirmed these delays, with explanations including a high number of residents to medicate, residents requiring preparation for appointments, and attending to residents with acute symptoms. The facility's policy requires medications to be administered within a two-hour window around the scheduled time, which was not adhered to in these instances. Residents affected included individuals with varying levels of cognitive impairment and intact cognition, all of whom expressed a preference for receiving their medications on time. Medication Administration Records (MAR) and Physician Orders Sheets (POS) confirmed that prescribed medications, such as antihypertensives, anticoagulants, and other daily medications, were not administered within the required timeframe. The Director of Nursing acknowledged that staff are expected to follow the five rights of medication administration, including the right time, and that the observed practice did not meet this standard.