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Based on the onsite investigation, completed 10/3/19, the facility failed to comply with the regulations set forth for Life Safety and, therefore, deficiencies were cited under Life Safety Code Tags K345, K353, K712, and K918. See survey event ID #07CT21 for full details of the cited deficiencies.

Based on document review and interviews, the facility failed to ensure medications designated as time-critical were administered in a timely manner according to the provider's order and the facility's policy. The failure was identified in 3 of 30 inpatient medical records reviewed (Patient #8, #16, and #18).

Findings include:

Facility policy:

The Nursing Department policy, Medication Administration, read "medications are administered at scheduled dosing times". Time-critical medications to include, but not limited to, insulin medications, anticonvulsants, anticoagulants, immunosuppressive drugs, medications prescribed for specific timing, or to be given apart from other medications must be administered within 30 minutes before or after their scheduled dosing time. The total window of time for medication administration may not exceed one hour.

1. The facility failed to ensure medications designated as time-critical were administered in a timely manner according to the provider's order and the facility's policy.

a. A record review was completed for Patient #8, admitted to the facility on 8/5/19. According to the Health and Physical (H&P) completed on 8/6/19, the provider documented the patient was an insulin-dependent diabetic.

According to the Medication Administration Record (MAR) section, Patient #8 was ordered to receive Humilin-R insulin (a short-acting insulin medication used to treat insulin-dependent diabetes) on a sliding-scale scheduled four times. The patient was also ordered to receive insulin glargline, or Lantus (a long-acting insulin medications used to treat insulin-dependent diabetes) twice a day.

Review of the MAR between the dates of 8/5/19-8/10/19 and 8/21/19-8/28/19 identified examples of insulin medications, both regular and long-acting Lantus, which were not administered in a timely manner according to the provider order and the Medication Administration policy.

Examples of Humilin R administration from 8/5/19 to 8/22/19 included:

The dose scheduled for 8/22/19 at 4:00 p.m. was not administered until 9:05 p.m.
The dose scheduled for 8/9/19 at 11:00 a.m. was not administered until 4:59 p.m.
The dose scheduled for 8/8/19 at 12:00 p.m. was not administered until 7:00 p.m.

Examples of Lantus administrations from 8/5/19 to 8/26/19 included:

The dose scheduled for 8/25/19 at 8:00 a.m. was not administered until 11:35 a.m.
The dose scheduled for 8/26/19 at 8:00 a.m. was not administered until 11:15 a.m.
The dose scheduled for 8/22/19 at 8:00 a.m. was not administered until 2:14 p.m.
Review of the record no documentation with the reason for the delay in medication administrations.

b. A record review was conducted for Patient #16 who was admitted on 8/23/19. The history and physical (H&P) documented the patient as an insulin-dependent diabetic with an inpatient plan to treat with Lantus and a low-dose sliding scale short-acting insulin (insulin regular) during the patient's stay.

Review of the patient's MAR also identified untimely administration of "time-critical" insulin medications according to the facility's policy.

Examples of untimely Regular-Insulin medication administration per policy included:

The dose scheduled for 8/24/19 at 4:00 p.m. which was not administered until 7:09 p.m.
The dose scheduled for 8/25/19 at 8:00 p.m. was not administered until 9:57 p.m.
The dose scheduled for 8/10/19 at 8:00 p.m. was not administered until 9:20 p.m.

Similar findings of delayed administrations for the short-acting insulin were noted with the 8:00 a.m. doses scheduled on 9/10/19, 9/11/19 and 9/12/19.

Similar findings were also noted for the Lantus doses scheduled from 8/15/19 to 9/17/19, where medications were not consistently administered within the timeframe required for time-critical medications.

On review of the record there was no documentation with the reason for the delays in medication administrations.

c. A record review was completed for Patient #18, who was admitted to the facility on 5/25/19. According to the H&P completed on 5/26/19, the provider documented Patient #18 had a diagnosis of epilepsy (a seizure disorder) and hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone).

According to the MAR, Patient #18 had orders to receive the following anticonvulsants for his seizure disorder: Depakote Extended Release (ER) 1000 milligrams (mg) two times a day, as well as an additional dose which was scheduled for 2:00 p.m., Dilantin 300 mg daily, Topamax 50mgs two times a day, Neurontin 300 mg three times a day and Keppra 250 mg two times a day.

Review of the MAR between the dates of 5/25/19-8/10/19 and 8/21/19-9/18/19 found multiple examples of the following anticonvulsants: Depakote ER, Dilantin, Topamax, Neurontin and Keppra were not administered in a timely manner according to the provider orders and the Medication Administration policy related to administering time-critical medications.

Examples included the following for Depakote ER administrations:

The dose scheduled for 5/26/19 at 2:00 p.m. was not administered until 4:25 p.m.
The dose scheduled for 6/4/19 at 8:00 a.m. was not administered until 10:09 a.m.
The dose scheduled for 6/5/19 at 2:00 p.m. was not administered until 4:21 p.m.

Similar findings were found in the MAR in which multiple doses of Dilantin, Topamax, Neurontin and Keppra were not administered in a timely manner per facility policy.

According to the MAR Patient #18 had orders to receive Levothyroxine 100 micrograms (mcg) daily at 6:00 a.m., for hypothyroidism.

Review of the MAR between the dates of 5/25/19-8/10/19 and 8/21/19-9/18/19 found multiple examples the thyroid medication, was not administered in a timely manner according to the provider order and the Medication Administration policy related to administering time-sensitive (time-critical) medications. Examples include the following:

On 6/4/19, the dose was administered at 10:07 a.m.
On 6/9/19, the dose was administered at 9:43 a.m.
On 6/23/19, the dose was administered at 7:02 a.m.

d. On 9/25/19 at 10:58 a.m., an interview was conducted with a registered nurse (RN #1) and RN #2. RN #1 stated the MAR in the Electronic Health Record (EHR) identified colors when medications were due. Green indicated a medication was due to be given and red indicated a medication was overdue. RN #1 stated the expectation was to give all medications when they were ordered/scheduled to be administered. RN #1 stated time-sensitive (time-critical) medications were insulin, cardiac medications, anticoagulants and any medication which was extended or slow release. RN #1 stated there was no indicator on the MAR to indicate which medications were time sensitive, but she knew which medications were time-sensitive based on which medication class the medication was identified as.

RN #2 stated insulin was a time-sensitive medication and was required to be administered within one hour prior to the scheduled time, or up to one hour after the scheduled time. RN #2 stated all medications alerted the nurses on the MAR with a green color when the medication was allowed to be given and included time-sensitive medications. RN #2 stated insulin should be given while patients were eating their scheduled meals. RN #2 stated if medications were not given within the allotted time frame, the alert would turn red, the nurse would then notify the provider to ensure it was acceptable to administer the medication late and the nurse would make a comment on the MAR which indicated why the medication was late and the provider was aware.

e. On 9/25/19 at 9:25 a.m., an interview with the Director of Pharmacy (Director) #3 was conducted. Director #3 stated the administration window for medications was one hour prior to the scheduled time and one hour after the scheduled time. Director #3 stated she did not audit whether insulin was administered within the facility's outlined timeframes in the policy. Director #3 stated insulin was used to help the body metabolize glucose present in the body and was most commonly administered within 30 minutes of the patient's meal in order to prevent glucose levels from spiking after eating.

Director #3 stated anticonvulsants were administered to prevent seizure activity. She stated it was important to give anticonvulsants as scheduled to maintain a therapeutic level of medication within the body.

Director #3 stated Levothyroxine was a thyroid hormone replacement. She stated Levothyroxine was scheduled daily at 6:00 a.m. because it was important not to give it with food or other medications due to the probability it would interact and not be effective.

f. On 9/25/19 at 2:03 p.m., an interview was conducted with the director of nursing (DON #4). According to the interview, time-sensitive medications were listed in their policy and staff were expected to follow provider orders and facility policy when administering medications. DON #4 stated if time-sensitive medications could not be administered within the expected timeframes, the nurse should document the reason why in the medical record and notify the physician.

DON #4 stated she was unsure if nurses received formal training regarding the administration expectations for time-sensitive medications.

g. A document review was conducted of the Pharmacy Orientation for Nurses which was provided by DON #4. Review of the document found no evidence time-critical medication was covered in the orientation material provided to the nursing staff.