Repeated Late Administration of Scheduled Medications for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely and accurate medication administration for two residents. For Resident #1, who had hypertension, low back pain, and atrial fibrillation and was severely cognitively impaired (BIMS score 5/15), multiple scheduled morning medications ordered for 7:00 AM were repeatedly administered between approximately 10:00 AM and 10:45 AM over three consecutive days. These medications included apixaban, polyethylene glycol, thiamine, a multivitamin-mineral supplement, megestrol acetate, levetiracetam, ascorbic acid, metoprolol tartrate, and a lidocaine patch. Medication Administration Audit Reports dated 01/08/26 documented that on 01/06/26, 01/07/26, and 01/08/26, the same staff member (MA A) administered these medications significantly later than the scheduled time. Resident #2, who had depression, acute on chronic right heart failure, hypertension, a non-ST elevation myocardial infarction, and severe cognitive impairment (BIMS score 1/15), also experienced late administration of multiple 7:00 AM medications. The order summary for this resident included Lexapro, artificial tears, aspirin, calcium, Namenda, Aldactone, ferrous sulfate, carvedilol, and Bumex. The Medication Administration Audit Report for 01/08/26 showed that all of these medications, scheduled for 7:00 AM, were administered at 10:57 AM by the same medication aide, MA A. These findings demonstrated that the facility did not ensure medications were administered according to the ordered times. In interviews, MA A acknowledged that medications for these residents were given late and stated she was trying to coordinate medication administration around therapy sessions and resident appointments, but admitted this was not an excuse. The DON stated that it was not a pattern for residents to receive medications late and that if medications were late, the physician would be called, and noted that therapy and family visits could affect administration times. The Interim Administrator reported that the facility did not have a policy specifying the time frame for when medications should be given, and that staff followed an internal “Medication Times” reference sheet indicating day-shift medication times between 7:00 AM and 10:00 AM and between 12:00 PM and 2:00 PM. The survey findings concluded that the facility failed to provide pharmaceutical services that assured accurate acquiring, receiving, dispensing, and administering of medications, which could place residents at risk of not receiving the intended therapeutic benefit and worsening of chronic conditions.
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