Failure to Ensure Residents Are Free from Significant Medication Errors Due to Late Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple instances of late medication administration for three residents with complex medical conditions. For one resident with diagnoses including diabetes, heart failure, and cerebral infarct, medications such as insulin, antidiabetics, diuretics, and anticonvulsants were repeatedly administered outside the prescribed time frames, sometimes several hours late. The resident confirmed that medications, including insulin, were often given late, particularly when agency nurses were on duty. Medication administration records corroborated these delays, and staff interviews revealed that workload, interruptions for resident care, and unfamiliarity with residents contributed to the late administration. Another resident with diabetes, dementia, and hypertension also experienced late administration of critical medications, including Humalog and Lantus insulin. Documentation showed that insulin doses intended to be given with meals or at bedtime were administered significantly later than ordered. Staff interviews indicated that high workload, the need to verify medications, and interruptions during medication passes were common reasons for these delays. The resident's blood sugar records did not show significant abnormalities during the review period, but the pattern of late administration was consistent. A third resident with chronic conditions such as COPD, chronic kidney disease, and repeated falls also received medications late, including gabapentin and Seroquel. This resident reported not always receiving medications as ordered. Multiple nursing staff, including RNs and LPNs, acknowledged that medications were sometimes administered late due to factors such as high resident acuity, the need to provide direct care, technical issues with electronic systems, and the challenge of managing large numbers of residents per shift. The facility's own medication administration policy emphasized the importance of timely administration, but adherence was not consistently maintained.