Failure to Administer Medications on Time and Notify Physician
Summary
A deficiency occurred when a resident did not receive their scheduled 9 a.m. medications within the required timeframe. The medications, which included Pregabalin, Duloxetine, Famotidine, Fenofibrate, and several others, were not administered within one hour of the prescribed time as required by regulation and facility policy. The delay was confirmed during a medication area inspection and through interviews with nursing staff, who acknowledged that the medications were not given as ordered and that there was no documentation of administration on the Medication Administration Record (MAR) within the required window. Further review revealed that the resident had not received any of their scheduled morning medications by the time of the inspection, and the medications were ultimately administered at 12:29 p.m., more than three hours after the scheduled time. The resident confirmed in an interview that she had not received her morning medications and stated that she does not refuse medication when woken up. Nursing staff also confirmed that the physician was not notified of the missed doses, and no reason for the omission was documented in the resident's records. Additionally, the administration of the next scheduled doses occurred at 4:10 p.m., resulting in two sets of medications being given in close succession. There was no documentation that the resident was monitored or assessed for adverse reactions following the late administration of multiple medications, including anti-constipation and seizure medications. The facility's policy requires medications to be administered within one hour of the prescribed time, and the failure to do so, along with the lack of physician notification and monitoring, constituted the deficiency.
Plan Of Correction
C 0945 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/7/2025, the RN supervisor immediately assessed Patient 10 for any signs of adverse outcome regarding medications that were not administered on time per MD orders. Vital signs were taken and recorded as follows: BP=124/74, P=76, R=19, O2 Sat=96%, and Pain level=2/10. Patient 10 was deemed stable with no issues and remained verbally responsive, alert, and oriented x 4 with no apparent complaint at this time. MD and responsible party were notified. 2. On 10/7/2025, DON completed a one-on-one in-service with LVN 2 to discuss the P/P on timely medication administration. The emphasis was to be very careful in following the guidelines for patients' health and well-being under their care. DON also discussed the importance of "pour, pass, sign." DON reiterated that MD be notified of circumstances that lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring would be done to ensure patient safety, followed by accurate timely documentation. C) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, upon identification of deficient practice, DON, ADON, and RN Supervisor immediately interviewed all other charge nurses regarding any other medication administration delays that took place that day. No additional delays were identified, and no other residents were identified as being affected. MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: An in-service was completed by the DON on 10/28/2025 for all nursing staff on "Medication Administration" policy and procedures. The facility had implemented a Medication Pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor improved performance of Charge Nurses on proper and accurate medication administration. Any noted deviations will be corrected immediately, and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report weekly audit findings to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C 0965 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 4. On 10/07/2025, RN Supervisor immediately assessed patient 2 for any change of condition or abnormality of wounds - no redness, no discharge observed from affected sights (right thigh scab, right pleur x site, and spine suture site). MD was notified. LVN 4, who
Penalty
A nurse administered a resident's scheduled morning medications, including Keppra for seizures, more than one hour after the prescribed time. Facility policy and the DON confirmed that medications should be given within one hour of the scheduled time, but this standard was not met during the observed medication pass.
Late Administration of Scheduled Medications
Penalty
Summary
A deficiency was identified when a registered nurse administered a resident's scheduled 9 a.m. medications approximately one hour later than the prescribed time. The medications included aspirin, Zyprexa, vitamin D, and Keppra, which were observed being given at 10:57 a.m. The nurse confirmed that these were the resident's 9 a.m. medications and acknowledged they were administered about an hour late. The facility's policy and the Director of Nursing both stated that medications should be administered within one hour before or after the scheduled time unless otherwise ordered by a physician. The resident involved had a history of hypertension and traumatic brain injury, and required moderate assistance with certain activities of daily living, but had intact cognitive skills. The late administration of medications was observed during a medication pass, and the facility's records and staff interviews confirmed the deviation from the required medication administration schedule.
Plan Of Correction
C945: T22 DIV5 CH3 ART3-7231(a)(6) Nursing Service - Administration of Medication. Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, RN assessed Patient 2 for any adverse reactions related to the late administration of morning medications. There was no change in condition noted. On 3/10/2025, RN notified the attending physician of Patient 2 of the late administration with no new orders obtained. (To continue page 8 of 25) Identify any other residents who may have been affected by the deficient Practice. On 3/12/2025, audited the last 7 days of medication administration to ascertain if any other patients had been administered routine medications late. There were none other issues identified. Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, DSD initiated in-servicing of licensed nurses regarding the proper timing and administration of medications. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/12/2025, MRD will spot check medication administrations of 5 patients per week to ensure they are not being administered after they are due. (To continue page 9 of 25) These weekly audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by MRD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25 C1115: T22 DIV5 CH3 ART3-72315(m) Nursing Service - Patient Care Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, RN placed the call light in reach of Patient 1. On 3/10/2025, RN answered the call light and attended to the needs of Patient 4. Identify any other residents who may have been affected by the deficient Practice. On 3/10/2025, ADONs and DSD made rounds of all in-house patients to ensure all call lights are in place and within reach. There were none other issues identified. On 3/10/2025, ADONs and DSD made rounds of all units to ensure staff is not walking past call lights that are engaged and ensuring that all call lights have been answered. There were none other issues identified. (To continue page 11 of 25)
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