F0684

E

Widespread Late Administration of Scheduled Medications

Clarion, Pennsylvania Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide resident-directed care and treatment consistent with physician orders and professional standards of practice for medication administration. Facility policy titled "Administering Medications" requires that medications be administered in accordance with prescriber orders, including required timeframes, and within one hour of the prescribed time unless otherwise specified. Review of medication administration records for two evening shifts showed that numerous scheduled medications were administered more than one hour late for 37 of 62 residents. On one evening, multiple residents had medications scheduled for 8:00 p.m. that were not administered until between approximately 10:05 p.m. and 11:12 p.m., and one resident had a 6:30 p.m. medication administered at 8:31 p.m. Another resident’s medications scheduled for 8:00 p.m. were not given until after midnight.

On the subsequent evening shift, additional residents had medications significantly delayed beyond the one-hour window. Medications scheduled for 4:30 p.m., 5:00 p.m., 6:30 p.m., 7:00 p.m., and 8:00 p.m. were administered between approximately 7:21 p.m. and 10:44 p.m., with some 4:30 p.m. and 5:00 p.m. medications not given until after 8:30 p.m. and as late as 10:43 p.m. These delays affected residents receiving single medications as well as those receiving multiple medications at a time, including instances where residents had up to 11 or 12 medications scheduled for a specific time that were administered several hours late. During a phone interview, the Nursing Home Administrator confirmed that the listed medications were administered late. The cited deficiency is related to Pennsylvania regulations governing responsibility of the licensee, management, and nursing services.