Failure to Administer Medications Timely Due to Staffing Issues
Penalty
Summary
The facility failed to administer medications to residents in a timely manner as prescribed, affecting three out of five residents reviewed for medication administration. Medical record review showed that one resident with diagnoses including intraspinal abscess, syphilis, anxiety, and bipolar disorder received trazodone for insomnia more than 90 minutes late on multiple occasions. Another resident with acute kidney failure, muscle weakness, neuromuscular dysfunction of the bladder, and paraplegia received oxycodone for pain more than 90 minutes late on several nights. A third resident with a left femur fracture, muscle weakness, dysphagia, and chronic kidney disease received gabapentin for pain more than 90 minutes late on two occasions. Staff interviews confirmed that medications were often administered late at night due to insufficient nursing staff, and the facility's policy requires medications to be administered within one hour of the prescribed time. The late administration of medications was verified for each resident on the specific dates listed in the medical administration records. This deficiency was identified during a complaint investigation and is documented under the relevant complaint number.