Failure to Provide Timely Medication Administration and Personal Care
Penalty
Summary
Facility staff failed to provide timely medication administration to a resident who was admitted with multiple diagnoses, including Parkinson's disease, muscle atrophy, diabetes type 2, hypertension, and anemia. The resident was cognitively intact, able to make her own decisions, and was totally dependent on staff for activities of daily living. Despite care records indicating that a bath was given every morning, the resident was observed to be soiled in bed with soiled linens for several hours during the survey, and her room had a pervasive odor of urine, feces, and body odor. The resident reported that medications were often administered late, sometimes hours after the scheduled time, and attributed this to insufficient staffing. Review of the medication administration records for March, April, and May revealed multiple instances where medications were given significantly later than ordered, including one occasion where a set of medications scheduled for the evening was not administered until the following morning, resulting in an 11-hour delay. Facility policy and the resident's care plan both required medications to be administered according to physician orders, but these were not followed. The deficiency was confirmed through resident and staff interviews, clinical record review, and facility documentation.