Medication Administration Delays and Incomplete Narcotic Count Records
Penalty
Summary
The facility failed to ensure timely administration of medications for three of six sampled residents. For one resident with schizoaffective disorder, major depressive disorder, and hypertension, medications such as lithium carbonate, lisinopril, risperdal, and gabapentin were not administered at the scheduled times, with documentation showing administration occurred significantly later than ordered. Another resident with schizophrenia, type 2 diabetes, and hypertension also experienced delays in receiving medications including empagliflozin, metformin, lisinopril, and risperdal, with records indicating these medications were given well after the scheduled times on multiple days. A third resident with schizoaffective disorder, epilepsy, and dementia had similar delays in receiving levetiracetam, memantine, haloperidol, and divalproex sodium, as shown by medication administration records and audit reports. Interviews with licensed vocational nurses confirmed that medications were administered more than one hour after the scheduled times, which was acknowledged as contrary to facility protocol and physician orders. The nurses stated that medications should be given within one hour before or after the scheduled time, and that delays occurred when residents initially refused medications or due to other factors. The actual times of administration were not always accurately documented, and staff recognized that such delays could affect residents' moods and symptoms. Additionally, the facility failed to maintain complete and accurate controlled drug count records for two of three medication carts. Reviews of the narcotic count sheets revealed multiple blank, unsigned spaces where licensed nurses had not signed at shift changes, as required by facility policy. Interviews with nursing staff confirmed that the count sheets should be signed at every change of shift after narcotics are counted, and that missing signatures indicated a lapse in accountability for controlled substances.