Failure to Ensure Timely Medication Administration
Penalty
Summary
The facility failed to ensure timely administration of medications for two of three residents reviewed for late medications. Record review and interviews revealed that one resident, who was cognitively intact and had diagnoses including quadriplegia and an unhealed stage three pressure ulcer, reported receiving medications either too early or late. The medications involved included Tylenol, Gabapentin, Baclofen, and Tizanidine, all of which were prescribed to be administered four times daily. The resident stated that late administration affected the timing of subsequent doses, causing them to be too close together. Audit reports from the electronic medical record showed multiple instances where medications were administered significantly outside the scheduled times, ranging from 42 minutes to over three hours late. These delays occurred repeatedly over several dates and involved various scheduled doses throughout the day and night. The medications affected were primarily for pain and muscle spasm management, and the late administration was consistently documented in the facility's records. The facility's policy, as reviewed in staff meeting documentation, required medications to be administered within one hour before or after the scheduled time unless otherwise specified by physician orders. Despite this policy, the documented medication administration times for the affected residents did not comply with the required time frames, resulting in a failure to meet the pharmaceutical service needs of the residents as outlined by facility policy and physician orders.