Failure to Administer and Document Medications Timely
Penalty
Summary
Nursing staff failed to follow the facility's medication administration policy and procedure in several instances, resulting in deficiencies related to timely medication administration and proper documentation. For one resident with a history of seizures, hypotension, and acute kidney failure, scheduled medications including antipsychotics and anticonvulsants were not administered as ordered on one evening, and there were multiple instances where medications were given late or documentation was delayed. The Director of Nursing confirmed that the resident did not receive the scheduled medications and that the responsible nurse could not provide a reason for the omission. Additionally, two nurses admitted to documenting medication administration after completing medication passes for multiple residents, citing issues such as unreliable Wi-Fi, rather than immediately after each administration as required by policy. Another resident with metabolic encephalopathy, dementia, UTI, and arthritis had six medications scheduled for administration at a specific time in the morning. Observation revealed that these medications were administered more than one and a half hours late. The nurse involved acknowledged the delay and confirmed that medications should be administered on time according to physician orders to ensure effectiveness. A third resident with Parkinsonism, epilepsy, and COPD had multiple instances where scheduled medications for seizure control were documented as being administered late. Interviews with nursing staff revealed that documentation was not completed immediately after each medication was given, contrary to facility policy. Staff acknowledged that they should have documented each administration before proceeding to the next medication, but this was not consistently done.