Failure to Administer Medications Within Prescribed Time Frame
Penalty
Summary
The facility failed to administer medications within the required time frame of 1 hour before to 1 hour after the scheduled dosing time for five residents. Clinical record reviews, policy review, and staff interviews revealed that all five residents had multiple instances over a 15-day period where medications were given outside of this two-hour window. Specifically, each resident had medications scheduled up to four times daily, and the Medication Administration Audit Reports showed consistent deviations from the prescribed administration times for nearly every day reviewed. Facility policy, last revised in May 2023, directs staff to administer medications in accordance with physician orders and within the specified time frame. During an interview, the DON confirmed the expectation that medications should be given within the 1-hour window before or after the scheduled time. Despite this, the audit reports for all five residents demonstrated repeated failures to meet this standard, as medications were not administered as ordered by the physicians.