Failure to Administer Medications Within Required Time Frame
Penalty
Summary
The facility failed to administer physician-ordered medications within the required time frame for two residents who were cognitively intact and had multiple medical diagnoses, including hypertension, hyperlipidemia, anemia, and major depression. Review of the Medication Administration Records (MAR) for both residents over a 10-day period showed that morning and evening medications were frequently given more than one hour outside the scheduled time, contrary to facility policy. For one resident, morning medications due at 8:00 AM were administered after 9:00 AM on six out of ten days, and evening medications due at 8:00 PM were given after 9:00 PM on six out of ten days. There was also an instance where a blood pressure medication was administered at 0:40 AM instead of the scheduled 8:00 PM. The medications involved included antihypertensives, cholesterol-lowering agents, eye drops, iron, and over-the-counter medications. Interviews with the residents confirmed that medications were often late, with one resident stating they had reported the issue to their family. Staff interviews revealed that delays were attributed to interruptions from residents, nurses being assigned to multiple units, and extended medication administration times. The Director of Nursing confirmed the expectation that medications be administered within one hour before or after the scheduled time, acknowledging that delays could occur due to staff being called to other areas or resident requests. Facility policy required medications to be administered within 60 minutes of the scheduled time unless otherwise ordered by a physician.