Failure to Administer Medications Timely for a Resident
Penalty
Summary
The facility failed to ensure timely administration of medications for one resident, as required by policy and physician orders. Record review and interviews revealed that the resident, who had diagnoses including end stage renal disease, type 2 diabetes, ascites, amputation, and sleep apnea, did not consistently receive medications at the scheduled times. The resident reported receiving medications due at 7:00 AM as late as 9:40 AM, and evening medications up to 45 minutes late. Documentation confirmed multiple instances where medications were administered between two hours and 48 minutes to five hours and 48 minutes after the scheduled times. Medications affected included melatonin, pantoprazole, rifaximin, sertraline, and atorvastatin. Staff interviews indicated that late medication passes were related to staffing issues. The DON stated that the expectation was for medications to be administered within one hour before or after the scheduled time, in accordance with facility policy. However, it was observed that nurses sometimes documented medication administration at the end of the day rather than immediately after administration, making it unclear if the documentation accurately reflected the actual administration times. The facility's policy required medications to be administered within 60 minutes of the scheduled time unless otherwise ordered by a physician.