F0755

E

Failure to Administer Medications per Orders and Standards Under Flex-Time System

Bellingham, Washington Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to consistently provide pharmaceutical services that ensured medications were acquired, scheduled, and administered in accordance with prescriber orders, manufacturer guidelines, and the facility’s own policies. The facility’s “Medication and Flexible Pass Time” policy allowed broad administration windows (AM 6:00–11:00, noon 11:00–2:00, evening 2:00–7:00, HS 7:00–10:00) and defined routine medications as time-specific orders that could be given one hour before or after the scheduled time. Surveyors found that, in practice, medications were not administered within these parameters and were not consistently spaced according to general medication guidelines. Staff interviews showed that nurses relied on the flex-time windows and did not always know or document the exact administration times on the MAR, requiring separate reports to determine when doses were actually given.

For one resident receiving acetaminophen (APAP) 1000 mg three times daily for pain and levetiracetam 1000 mg twice daily for seizures, the MAR showed APAP scheduled at AM flex pass, 11:00, and 8:00 p.m., and levetiracetam at AM flex pass and 4:00 p.m. The Medication Administration Audit Report (MAAR) documented multiple late or irregular doses. On several dates, the 11:00 APAP dose was given significantly late (e.g., at 1:41 p.m. and 1:34 p.m.), outside the one-hour window after the scheduled time. Levetiracetam doses were also given late or too close together, including a 4:00 p.m. dose administered at 8:46 p.m. and another day when the two daily doses were only five hours and 24 minutes apart, deviating from consistent interval guidelines.

For a second resident receiving APAP three times daily and multiple daily doses of carbidopa-levodopa for Parkinson’s disease, the MAAR showed that carbidopa-levodopa was not administered in accordance with orders specifying dosing one hour before breakfast and one hour before or after meals. Morning doses ordered one hour before breakfast were given around 5:00 a.m., while breakfast was served between 7:50 and 8:00 a.m. Midday doses ordered one hour before or after lunch were administered approximately one hour before the scheduled lunch time, and an afternoon dose scheduled at 3:30 p.m. was set two hours before dinner, contrary to the order to give one hour before or after the meal. Evening doses ordered one hour before or after a meal were given at various times not clearly aligned with meal times. This resident’s APAP doses were also administered with very short intervals between the morning and 11:00 doses, sometimes less than three hours apart.

For a third resident receiving APAP 1000 mg three times daily and carvedilol 6.25 mg twice daily ordered after meals, the MAR scheduled APAP at AM flex pass, 11:00, and 8:00 p.m., and carvedilol at AM flex pass and 4:00 p.m., without aligning carvedilol with meals as ordered. The MAAR showed instances where APAP doses were given late or too close together, including one day when the AM dose was given at 11:32 and the 11:00 dose at 11:59, resulting in 2000 mg of APAP administered 27 minutes apart. Carvedilol doses were also given late relative to the scheduled times. Additionally, this resident had an order for fosfomycin tromethamine “every 10 days in the evening…give with breakfast,” but the MAR scheduled it at 4:00 p.m., and there was no documentation in the EMR clarifying whether it should be given in the evening or with breakfast. During interview, the DON acknowledged the order was written in a confusing manner and would need clarification, and also recognized that the MAR did not show exact administration times, which could only be determined by running a separate report.

Staff interviews further demonstrated inconsistent understanding and application of flex-time and dosing intervals. LPNs and an RN stated that AM flex time allowed administration between 6:00 and 11:00 a.m. and that for twice-daily or three-times-daily medications they would “spread out” doses as best they could, but they did not reference specific intervals or manufacturer guidelines. When asked how nurses would know the exact time a flex-time dose was given before administering the next scheduled dose, the DON initially stated it was documented on the MAR, then acknowledged that the MAR did not show exact times and that a separate report was needed. The survey report states that these failures to administer drugs and biologicals per physician orders and standards of nursing practice placed residents at risk for medication errors, unmet health care needs, and decreased quality of life.