Failure to Ensure Timely and Accurate Medication Administration
Penalty
Summary
The facility failed to ensure timely and accurate medication administration for two of five residents reviewed. Facility policy requires medications to be administered safely and in accordance with prescriber orders, including specified time frames. For one resident with Parkinson's disease and seizure disorder, multiple medications scheduled for morning administration were significantly delayed, with some not given until late afternoon or evening. Another resident with congestive heart failure, hypertension, depression, and atrial fibrillation had not received their scheduled morning medications by mid-morning during surveyor observation. The facility's medication administration schedule allows for a one-hour window before or after the scheduled time, but these delays exceeded that window. Observations revealed a nurse assigned to 31 residents was still completing the morning medication pass well after the scheduled times. The nurse was also observed leaving medications unattended while assisting another resident, which is not standard practice. Additionally, the facility grievance log documented complaints from residents and family members regarding delayed medication administration, with findings confirming delays occurred. These events demonstrate a pattern of untimely medication administration and failure to follow facility policy.