Failure to Administer Medications at Prescribed Times
Penalty
Summary
The facility failed to administer medications as scheduled for two of five residents reviewed for pharmacy services. For one resident with severe cognitive impairment and multiple diagnoses, including generalized anxiety disorder and neurocognitive disorder, medication administration records showed that clonazepam and baclofen were not given at the prescribed times. Doses were administered several hours late or too close together, with some doses given less than an hour apart, contrary to the scheduled intervals. Observations confirmed that medications were administered outside the prescribed timeframes. Another resident, who was cognitively intact and had diagnoses of mood disorder and major depressive disorder, also did not receive medications as scheduled. Buspirone and gabapentin, both ordered three times daily, were administered hours late or with insufficient intervals between doses. Medication administration records and direct observation documented these timing discrepancies. Interviews with staff revealed a lack of consistent understanding and adherence to medication administration timing policies. A certified medication aide stated that medications could be given within a one-hour window of the scheduled time, but did not check the last administration time for medications given multiple times a day. The assistant director of nursing and director of nursing described a more liberalized approach to medication timing, but were unclear on procedures for medications scheduled more than once daily. Facility policy required medications to be administered within one hour of the prescribed time, unless otherwise specified, but this was not followed.