Failure to Administer Medications Timely as Ordered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as nursing staff did not administer medications according to physician orders. Medical record reviews, staff and resident interviews, and policy review revealed that six out of seven residents reviewed for late medications received their prescribed medications significantly past the scheduled administration times. The facility's policy required medications to be administered within one hour of the prescribed time, but medications were often given several hours late. Residents affected had various medical diagnoses, including acidosis, coronary artery disease, heart failure, renal insufficiency, chronic obstructive pulmonary disease, diabetes, dementia, and psychotic disorders. For example, one resident with heart failure and renal insufficiency received multiple medications, including anticonvulsants, cholesterol medication, and insulin, more than an hour late. Another resident with chronic obstructive pulmonary disease and diabetes received medications such as atorvastatin, divalproex, insulin, and antipsychotics up to three hours late. Several residents reported in interviews that their medications were consistently late and expressed a preference for receiving them on time. Staff interviews indicated that late medication administration was due in part to workload issues, such as responding to resident falls, and a lack of available assistance, as there was no unit manager present and other nursing staff were occupied with their own medication passes. The nurse practitioner confirmed that she was not informed of the late medication administration. The facility's policy on medication administration was not followed, resulting in non-compliance with prescribed medication schedules for multiple residents.