Failure to Administer and Report Late Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate and timely administration of medications for a resident with multiple complex medical conditions, including hypertension, epilepsy, heart failure, cerebral infarction, anxiety, dementia, and depression. The resident required maximal assistance with activities of daily living and had a moderately impaired cognitive status. According to the medication administration record, several medications were scheduled to be administered in the morning at specific times, including anticonvulsants, antidepressants, antihypertensives, and supplements. On the observed date, the medication aide (MA) did not administer the resident's morning medications at the scheduled times, instead giving all morning medications at 10:49 a.m., which was significantly later than the prescribed times ranging from 7:00 a.m. to 9:00 a.m. The MA acknowledged during interviews that she was late in passing medications and did not follow the physician's orders. She also admitted to not reporting the late administration to the nurse as required by facility policy. The nurse and DON confirmed they were not informed of the late administration, and both stated that timely medication administration is critical for the resident's conditions. Facility records indicated that medications are considered timely if given within one hour before or after the scheduled time, a standard that was not met in this instance. The facility's procedures require staff to report late medication administration to the nurse, who would then assess the resident and notify the physician for further instructions. The failure to administer medications on time and to communicate the delay to appropriate clinical staff constituted a deficiency in pharmaceutical services as required by facility policy and regulatory standards.