Failure to Administer Medications Timely and Notify Providers
Penalty
Summary
Surveyors identified that the facility failed to ensure residents received medications in accordance with provider orders and professional standards of practice. Observations, interviews, and record reviews revealed that four residents did not receive their scheduled medications within the prescribed time frames. The facility's policy required medications to be administered as ordered, and for staff to notify medical providers if medications were given late. However, medications were consistently administered late across various units, and there was no documented evidence that medical providers were notified of these delays. Specific incidents included residents with complex medical conditions such as fractures, dementia, hypertensive crises, heart failure, and anxiety disorders. For example, one resident with hypertension and dementia was scheduled to receive a Lidocaine patch and Metoprolol at specific times, but these were administered late. Another resident with heart failure and respiratory issues received Bumetanide later than ordered, and questioned the nurse about the inconsistent timing. In each case, the responsible LPNs acknowledged the delays, citing reasons such as heavy medication passes, computer system issues, and residents being unavailable due to appointments or meetings. Despite staff awareness of the need to notify medical providers about late medication administration, there was no documentation of such notifications in the electronic medical record. Interviews with nursing staff confirmed that while they sometimes verbally informed providers, they often forgot to document these communications. The facility also relied heavily on agency nurses, and staff reported that high workload and frequent interruptions contributed to the delays in medication administration.