Failure to Administer Medications Timely and Ensure Medication Availability
Penalty
Summary
The facility failed to ensure that prescribed medications were administered to residents in a timely manner, as required by facility policy and physician orders. For one resident with type 2 diabetes, obesity, and COPD, multiple weekly doses of Ozempic injections were not administered because the medication was not available on several scheduled dates across three months. Medication Administration Records (MARs) documented the absence of the medication, and the Director of Nursing (DON) attributed the issue to nurses not ordering medications on time, though no further explanation was provided for the missed doses. Another resident with Parkinson's Disease, type 1 and type 2 diabetes, and an amputation experienced delays in receiving morning medications, including insulin and Parkinson's medications. On the day of surveyor observation, the resident reported only receiving an early morning dose and was still waiting for the remainder of the scheduled medications after breakfast. The delay was due in part to the LPN needing to retrieve medication cart keys after being temporarily absent from the facility. The LPN confirmed that the resident's medications, including insulin, had not been administered on time and had not performed a blood sugar check prior to breakfast. Review of the MAR and physician orders confirmed that several medications were either marked as given on time despite being administered late or were documented as not available. The DON acknowledged awareness of the late administration and high blood sugar reading but could not explain discrepancies in MAR documentation. No additional information was provided regarding the reasons for the late or missed medication administration.