F0684

D

Repeated Late Medication Administration and Poor Documentation of Insulin and Other Medications

Norristown, Pennsylvania Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer medications within the time parameters ordered by physicians and outlined in facility policy for three cognitively intact residents. The facility’s undated "Administration of Medication" policy states that medications are to be given within 60 minutes before or after the designated administration time, with before‑meal medications given approximately 30 minutes before meals and after‑meal medications given no later than 30 minutes after meals. The facility’s meal delivery schedule shows defined breakfast, lunch, and dinner delivery windows, and the Food Director and Nursing Home Administrator both reported no concerns with late delivery of food trucks. There was no documented evidence of actual food delivery times. Despite this, multiple medication administration records (MARs) showed repeated late administrations without documented reasons or physician notification.

For one resident with type 2 diabetes and hypertension, the MAR from late December showed numerous late administrations of carvedilol and insulin lispro. Carvedilol, ordered twice daily within specified time windows, was repeatedly given well after the ordered time ranges, including evening doses administered between approximately 8:18 p.m. and 9:21 p.m. when the ordered window was 5:00 p.m. to 7:00 p.m., and a morning dose given at 10:39 a.m. when the ordered window ended at 10:00 a.m. Insulin lispro ordered before meals and at bedtime was also frequently administered late, including morning, midday, afternoon, and bedtime doses given significantly after the scheduled times, some several hours after the ordered administration time. Documentation on the MAR typically noted "charted late" or similar brief comments, but there was no documented evidence of reasons for the delays or of physician notification. This resident reported that medications are often late.

A second resident with a hip replacement and type 2 diabetes, cognitively intact, reported that insulin is often given long after meals, sometimes a few hours, despite being ordered to be given prior to meals. Review of this resident’s MAR for early to mid‑January showed repeated late administrations of scheduled pre‑meal insulin lispro doses. Morning, midday, and evening doses ordered within specific time ranges were frequently administered well after those ranges, including midday doses given more than an hour or several hours after the ordered window and morning doses given after the end of the scheduled time frame. Each late dose was documented as "charted late" with minimal comments such as "n/a" or similar, and there was no documented evidence of reasons for the late administration or physician notification.

A third resident with a scapula fracture and type 2 diabetes, also cognitively intact, reported that morning medications are received late and that medications are always late, especially at night. Review of this resident’s MAR from late December through January showed late administration of antihypertensive and pain medications. Amlodipine ordered for morning administration within an 8:00 a.m. to 11:00 a.m. window was given after 11:00 a.m. on multiple occasions, and oxycodone ordered twice daily within specified morning and afternoon/evening windows was administered after the end of those windows, including doses given after 7:00 p.m. or later when the ordered window ended at 7:00 p.m. These late administrations were documented as "charted late" or "other" with comments such as "N/A" or "ok," and there was no documented evidence of reasons for the delays or of physician notification. The Director of Nursing confirmed that when medications are late they must be manually entered and documented as late, corroborating the pattern of late entries noted in the MARs.