F0755

D

Untimely Medication Administration Resulting in Medication Error

Evansville, Wisconsin Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely administration of medications in accordance with physician orders and facility policy for one resident. The facility’s “Administering Medications” policy required medications to be administered per provider orders, with verification of the right medication, dose, route, time, and resident identity, and specified that medications should be administered within one hour of the prescribed time. The “Medication Error and Drug Interactions” policy defined a medication error as preparation or administration of medications not in accordance with the prescriber’s order. For the resident reviewed, physician orders for February 2026 included Potassium Citrate-Citric Acid oral solution via G-tube four times daily for kidney stones, Oxybutynin Chloride oral solution via G-tube three times daily for urinary leakage, and Gabapentin oral solution via G-tube three times daily for pain.

Record review of the Medication Administration Audit Report showed that all three medications, scheduled for 8:00 AM on a specific date, were actually administered at 9:18 AM, which was outside the facility’s defined one-hour window (7:00 AM to 9:00 AM) for an 8:00 AM dose. During interviews, an LPN and the DON both confirmed that medications scheduled for 8:00 AM must be given between 7:00 AM and 9:00 AM, and that administration outside this timeframe constitutes a medication error. This late administration of the resident’s ordered medications, beyond the facility’s established administration window, resulted in a medication error and demonstrated that pharmaceutical services were not provided in accordance with the facility’s own policies and the prescriber’s orders.