Failure to Administer Medications and Treatments Timely According to Orders and Standards
Penalty
Summary
The facility failed to ensure timely administration of medications, adherence to medical care orders, and compliance with professional standards of quality for one resident reviewed during a complaint survey. Multiple medications, including high-risk drugs such as antihypertensives, insulin, antibiotics, and wound care treatments, were not administered within the prescribed timeframes. The facility's policy outlined specific requirements for medication administration, including the need for certain medications to be given at exact times and for high-risk medications to be administered within one hour of the scheduled time. Despite these policies, audit reports showed that numerous medications were given several hours late over two consecutive days, and wound care orders were also not completed within the required shift times. Interviews with facility staff revealed that the delays in medication administration were attributed to staffing shortages and competing clinical priorities, such as a nurse attending to another patient in critical condition. Staff members, including an LPN and the Director of Clinical Operations, confirmed that medications like antibiotics, blood pressure medications, and insulin are expected to be administered within a strict one-hour window and should not be liberalized. However, the audit showed that these medications were not given within the required timeframes, and there was confusion regarding the scheduling and documentation of liberalized versus non-liberalized medications. Further, the Medical Director did not express concern about the timeliness of medication administration and deferred to facility staff and regulations for guidance. Documentation reviewed by the surveyor included a resident's complaint about not receiving short-acting insulin as ordered. Additional interviews with nursing leadership indicated that staff were performing multiple roles due to staffing shortages, which contributed to the failure to administer medications and treatments as ordered.