Failure to Administer Medications on Time Due to Staffing and Policy Lapses
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate and timely administration of medications for three residents. Review of medical records and medication administration records (MARs) showed that multiple medications, including Divalproex Sodium, Sacubitril-Valsartan, Aspirin, Baclofen, Buspirone, Potassium Chloride, Donepezil, and Pantoprazole, were administered significantly later than the scheduled times as indicated by physician orders. For example, medications scheduled for 7:00 AM were administered between two to over four hours late. The facility's policy required medications to be administered within one hour of their prescribed time, but this was not followed. The delays in medication administration were linked to staffing issues. One LVN reported working a 25-hour shift due to the oncoming nurse calling out for a family emergency, and the facility's administrative and staffing personnel were unable to find coverage. The LVN described feeling overwhelmed, exhausted, and not competent to safely administer medications after working such an extended period without rest. She communicated her concerns to the administrator but continued to work and administer medications despite her fatigue. Interviews with other nursing staff revealed inconsistent understanding of the facility's medication administration timeframes, with some stating a one-hour window and others referencing a more liberalized timeframe. The administrator was unaware of the specific timeframes for medication administration. The facility's policy emphasized safe and timely medication administration, but the observed practices did not align with these requirements, resulting in late medication administration for multiple residents with complex medical needs.