F0755

D

Failure to Administer Time-Sensitive Medications as Ordered

Buffalo, Missouri Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pharmaceutical services that met residents’ needs by not administering medications as ordered and not adhering to specified administration times. The facility’s own Medication Administration and Documentation policy allowed a liberalized medication pass with a three-hour window before and after scheduled times for certain oral medications, but it also stated that medications with a narrow therapeutic index, such as anticoagulants, should not be liberalized if ordered at a specific time on the MAR. The policy further indicated that medications are considered late if given more than three hours after their scheduled time and that missed doses require provider consultation. Despite this, staff did not consistently follow ordered times or document missed or late doses.

For one resident admitted with multiple pelvic fractures and on anticoagulant therapy, physician orders included apixaban 5 mg PO BID and flecainide 25 mg PO every 12 hours. The MAR for a ten-day period showed missing documentation for both the morning and evening doses on certain days and administration times that varied widely from the expected BID schedule, including doses given at 7:00 A.M., 8:01 P.M., 10:17 A.M., 6:29 P.M., 12:14 P.M., 7:10 P.M., 10:00 A.M., 6:58 P.M., 10:55 A.M., and 7:15 P.M. Nurses’ notes for this period did not contain documentation explaining missed doses or doses given outside the ordered time frame. The NP stated that apixaban should be given eight hours between doses and that giving it earlier would be a medication error, while the pharmacist indicated it was typically scheduled at 9:00 A.M. and 9:00 P.M. due to its half-life.

For another resident with a diagnosis including a sacral pressure ulcer and on anticoagulant medication, there was an order for metoprolol succinate 12.5 mg to be given daily at 6:00 A.M. The MAR showed that during the same review period, this medication was consistently administered much later in the morning, with times ranging from 9:20 A.M. to 11:10 A.M. Nurses’ notes contained no documentation related to these administrations occurring outside accepted time frames. Interviews with multiple staff, including CMTs, RNs, the NP, the pharmacist, the DON, and the Administrator, revealed inconsistent understanding of the liberalized medication pass, with varying descriptions of allowable time windows and which medications were considered time-specific, contributing to the failure to administer medications within the ordered or policy-defined time frames for these residents.