HospitalInspections.org

Staff Interview, medical record review, facility medication variance report review, and facility policy review confirmed Nursing staff did not follow facility policy and procedures for the timely administration of medications, resulting in medications administered late for four (4) of four (4) sampled patients between 10/28/2024 and 11/04/2024. Patients #1, # 2, #3 and #4.

Findings Include:

During an interview on 01/15/2025 at 2:20 p.m., the Director of Quality (DOQ) confirmed she was not aware of medications given late until she generated a facility medication Variance report today. The DOQ further confirmed when a scheduled medication is administered greater than 60 minutes before or after due time, the discrepancy will be identified on the variance report.

During an interview on 01/16/2025 at 10:30 a.m., the Director of Pharmacy (DOP) confirmed he was only aware of a delay in administering a nephrotoxic antibiotic. Further the DOP revealed he did not realize that other scheduled medications were being administered late until he generated this variance report today.

Review of Electric Medication Administration Record (EMAR) Variance Report for Patient #1 revealed on 11/01/2024 and 11/02/2024 the medications Docusate sodium 100 milligrams (mg) twice daily (bid) by mouth (p.o.), Aspirin 81 mg p.o. daily, Ticagrelor 90 mg p.o. bid, Atorvastatin Calcium 40 mg P.O bid were scheduled for 9:00 a.m. but administered after 12:00 p.m. by Registered Nurse (RN) #1.

Review of EMAR Variance Report for Patient #2 revealed on 11/01/2024 the medications Pantoprazole Sodium 40 mg Intravenous push (IVP) daily, Digoxin 125 micrograms (mcg) p.o. daily, Torsemide 40 mg p.o. daily, and potassium chloride 20 milliequivalent (meq) p.o. daily was scheduled for 9:00 a.m. but was administered after 12:00 p.m. by RN #1.

Review of the EMAR Variance Report for Patient #3 revealed on 10/31/2024 and 11/01/2024, the medications Pantoprazole Sodium IV 40 mg IVP daily, Prednisone 20 mg p.o. daily, Spironolactone 50 mg p.o. daily, Sacubitril/Valsar 24 mg/26mg p.o. daily, were scheduled for 9:00 a.m. but were administered at 11:01 a.m., and on 11/01/2024 the medication Piperacillin Sodium/Tazobactam 3.375 grams in 9% Sodium Chloride Intravenous Piggy Back (IVPB) was scheduled for 10:00 a.m. , was not administered until after 12:30 p.m. by RN #2.

Review of the EMAR Variance Report for Patient #4 revealed on 10/31/2024 and 11/01/2024, the medications Nifedipine XL 60 mg p.o. daily, Spironolactone 25 mg p.o. bid., Tamsulosin HCL 0.4 mg p.o. bid, Aspirin 81 mg, p.o. daily, Lisinopril 20 mg p.o. bid and Metoprolol Tartrate 50 mg bid were scheduled for 9:00 a.m. and was not administered until after 12:30 p.m. by RN #3.

Review of facility policy entitled "Medication Orders, PH.022," last review date 12/2023 revealed " ...scheduled medications include all maintenance doses administer according to a standard, repeated cycles of frequency ...Medicine schedules should only be altered when absolutely unavoidable. Scheduled medications are considered to be "late" when given more than one hour before or after the time the dose is due to be administered ... Time-critical medications are those where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy or paralogical effect ...defines such medications as: Antibiotics, Anticoagulants, Insulin, Anticonvulsants, Immunosuppressive Agents, Scheduled Pain Medications ...".

The Exit conference was conducted on 01/16/2024 at 12:10 p.m. with the Chief Nursing officer and Director of Quality. No other documents were submitted from the facility.