Significant Medication Timing Errors and Improper Insulin Borrowing
Penalty
Summary
The deficiency involves the facility’s failure to administer cardiac and related medications within required timeframes, resulting in significant medication errors for multiple residents. One resident received Hydralazine, ordered three times daily at 9:00 AM, 1:00 PM, and 9:00 PM, at 11:38 AM and 2:08 PM on one day, and at 11:10 AM and 2:30 PM on another day, outside the one-hour before/after window stated by the nurse. The same resident’s Metoprolol Tartrate, ordered at 9:00 AM and 8:00 PM, was administered at 12:02 PM for the morning dose, and the evening doses on two consecutive days were not given until early the following mornings (12:35 AM and 4:17 AM). During observation, the LPN administered the resident’s morning oral medications, including Hydralazine, then obtained elevated blood pressure readings and administered Metoprolol at noon, confirming that medications are supposed to be given within one hour of the scheduled time. Another resident with diabetes had a blood glucose of 49, and the LPN stated the resident was out of insulin and proceeded to borrow Novolog and Lantus from another resident’s vials before administering them, while also being behind on 8:00 AM medications for several residents as indicated by overdue (red) medication alerts. This resident’s Isosorbide, Metoprolol Tartrate, and Hydralazine were repeatedly administered late or too close together, including an evening Hydralazine dose given less than five hours before the next morning dose and other doses given many hours after the scheduled times. A third resident reported around midday that she had not yet received her morning medications; record review showed her Sacubitril-Valsartan and Furosemide, both ordered for CHF, were administered several hours late on multiple days, with some evening doses given in the early morning hours. Staff, including the LPNs and pharmacist, confirmed that the unit has a heavy medication pass, that the nurse often runs past the allowed medication window, and that these medications should be spaced at specific hourly intervals to avoid excessive or diminished effects.
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