Repeated Late Administration of Parkinson’s Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to the administration of Carbidopa-Levodopa for a resident with Parkinsonism. Facility policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required that medication errors be documented, reported, and reviewed by the QAPI committee. The resident’s physician orders specified Carbidopa-Levodopa 25-100 mg to be given three times daily at set times, with special instructions that the medication be administered one hour prior to meals per the resident’s home routine and with an added notation to “PLEASE GIVE ON TIME!” Despite these orders and policy requirements, the medication was repeatedly administered outside the one-hour window on at least 32 occasions over a one-month period, including multiple doses that were more than two, three, five, and even six hours late. The surveyor’s review of the electronic medication administration record showed numerous late administrations across different ordered schedules, including doses scheduled for morning, midday, and afternoon that were consistently given late. During interview, the resident reported concerns about not receiving medications on time and stated that they now self-administer medications as done at home. In a separate interview, the DON, who had recently started in the role, stated that medications are expected to be given within one hour before or after the scheduled time and that, if a medication is late, staff are expected to complete a medication error report and notify the physician and the resident or responsible party. The DON also acknowledged awareness of medication administration times as an issue and indicated that she did not believe staff were completing medication error reports. No additional information was provided by the facility to refute or explain the pattern of late administrations for this resident’s Carbidopa-Levodopa.
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