Failure to Administer Scheduled Medications Within Ordered Time Frames
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in accordance with physician orders, facility policy, and required time frames for one cognitively intact resident. Facility policy on medication administration dated December 2012 requires that medications be administered safely, timely, and as prescribed, including within one hour of the scheduled time unless otherwise specified, and that nursing personnel administering medications verify the right resident, medication, dose, time, and method. Resident R53 was admitted with diagnoses including hypokalemia, hypertension, congestive heart failure, diabetes, deep vein thrombosis, atrial fibrillation, neuropathy, and gout, and had multiple scheduled medications ordered for morning administration with meals or at specific times. Review of Resident R53’s Medication Administration Audit Report showed that on a specific date, multiple medications ordered for 9:00 AM administration were not given until after 4:00 PM. These included potassium chloride ER 20 mEq (2 tablets BID), Toprol XL 50 mg daily with meals for HTN, metformin 500 mg in the morning with breakfast for diabetes, Lasix 40 mg on designated days for CHF, Eliquis 5 mg BID for DVT, diltiazem 30 mg daily for A-fib, gabapentin 100 mg BID for neuropathy, and allopurinol 100 mg daily for gout. The resident reported that nurses give his medications very late, and a licensed nurse confirmed that medications scheduled for 9:00 AM on that date were documented as administered after 4:00 PM, demonstrating noncompliance with the facility’s medication administration policy and physician orders.
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