Failure to Administer Medications at Ordered Times
Penalty
Summary
The facility failed to ensure that medications were administered at the ordered times for one of three sampled residents reviewed for medication administration. According to the facility's policy, medications are to be administered by licensed nurses or other authorized staff as ordered by the physician, following the six rights of medication administration, including the right time. For a resident with diagnoses of heart failure, hypertension, and renal insufficiency, physician orders specified that Lasix was to be administered twice daily at 7:00 a.m. and 2:00 p.m. However, medication administration audit reports showed multiple instances where Lasix was not given at the ordered time, with doses being administered significantly later than scheduled on several dates. Interviews with staff revealed inconsistencies in following the facility's protocol regarding medication timing. An LPN stated that there was a one-hour window before and after the ordered time for administration, but acknowledged that some doses were given outside this window and could not explain the delays. The DON confirmed the protocol and stated that nurses should report late administrations, but there was no indication that this occurred. The documentation and staff interviews demonstrate that the facility did not consistently adhere to its own medication administration policies, resulting in late administration of prescribed medications.