Failure to Administer Medications Within Required Timeframe
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate and timely administration of medications for three out of five residents reviewed. Specifically, medications, including Carbidopa-Levodopa prescribed for Parkinson's disease, were not administered within the required timeframe for three residents. Medication administration records showed that doses were given outside the facility's stated one-hour window before or after the scheduled time, with some doses being administered significantly late. There were no supporting progress notes or documentation explaining the late administration for these instances. For one resident with severe cognitive impairment and multiple diagnoses including Parkinson's disease, hemiplegia, dysphagia, COPD, and dementia, Carbidopa-Levodopa was administered late on multiple occasions, with no documentation or notes to justify the delay. Another resident, with diagnoses including Parkinson's disease, urinary tract infection, hypertension, and soft tissue cancer, also received late administration of the same medication, again without supporting documentation. A third resident, who had Parkinson's disease, anxiety disorder, hypothyroidism, depression, and chronic pain syndrome, experienced both late and missed doses of Carbidopa-Levodopa, with no care plan in place and no documentation of the reasons for the missed or late doses. Interviews with medication aides and the DON revealed that staff followed an informal practice of administering medications within a one-hour window before or after the scheduled time, although this was not explicitly stated in the facility's policy. Staff admitted to giving medications late due to workload or being occupied on other halls, and often did not notify the charge nurse or document the late administration in the MAR. The DON, administrator, and nurse practitioner all expressed expectations that medication orders be followed as written and that any deviations be communicated to clinical staff, but were not aware of the specific late administrations at the time of the survey.