Failure to Administer Medications Timely According to Policy and Standards
Penalty
Summary
The facility failed to ensure that medications were administered to a resident in accordance with professional standards of quality and facility policy. Observation, interview, and record review revealed that a resident with multiple diagnoses, including bipolar disorder, anxiety disorder, heart failure, and hypertension, did not receive scheduled medications at the prescribed time. The resident's Medication Administration Record (MAR) indicated several medications were scheduled for administration at 8:00 A.M., but on the observed date, these medications were not administered until 10:15 A.M., which was two hours and fifteen minutes after the scheduled time. The resident also reported that medications were frequently not given at the scheduled times, including evening doses being administered late. Interviews with staff, including Certified Medication Technicians (CMTs), Registered Nurses (RNs), Certified Nurse Aides (CNAs), and the Director of Nursing (DON), confirmed that there were ongoing issues with timely medication administration. Staff consistently stated that medications should be administered within one hour before or after the scheduled time, and that administration outside this window is considered late and a medication error. Staff attributed the delays to high medication loads, with one CMT responsible for administering medications to up to 58 residents across multiple halls, making it difficult to adhere to scheduled times. Additional interviews with CNAs revealed that they had received complaints from residents about late medication administration, particularly in the afternoons. The DON and Administrator acknowledged the staffing assignments and the expectation that medications be administered as ordered, but were not aware of the extent of the delays until brought to their attention during the survey. The facility did not have an effective system in place to ensure timely medication administration, resulting in repeated late administration of medications to residents.