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Based on review of medical records, facility policies and procedures, and staff interview, it was determined that the facility's staff failed to administer medications according to the facility's medication policy for 1 of 3 (#3) patients.

Findings were:

A review of the facility's policy entitled "Medication Administration" #300-81 revealed that each patient is to receive the correct medication as ordered by the physician in a timely manner. The policy further specified that medications were to be given according to the "Five Rights"; Right: patient, drug, dose, time and route.

Review of patient #3's medical record revealed orders were written by the physician for medications to be given at specified times. Review of the patient #3's Medication Administration Record revealed the following medications were not given as scheduled:

Oscal/Oyst-Cal ( a calcium supplement) 500 mg by mouth was ordered to be given three times a day and was scheduled to be given at 9:00 a.m., 1:00 p.m. and 6:00 p.m. (after meals). On hospital day #2 the 1:00 p.m. was given at 4:24 p.m. which was 4 hours and 24 minutes after the scheduled time. On hospital day #4 the 1:00 p.m. medication was given at 5:47 p.m., which was 4 hours and 17 minutes after the scheduled time.

Humibid (used for upper respiratory tract infections) by mouth was ordered to be given 2 times a day and was scheduled to be given at 10:00 a.m. and 10:00 p.m. On hospital day 3, the scheduled 10:00 p.m. dose was given at 12:43 a.m., which was 1 hour and 43 minutes after the scheduled time.

Lasix (a diuretic) 20 mg by mouth was ordered to be given daily and was scheduled to be given at 8:00 a.m. On hospital day #4 the scheduled at 8:00 a.m. was given at 9:49 a.m., which was 1 hour and 49 minutes after the scheduled time.

Aspirin 81mg by mouth was ordered to be given daily and was scheduled at 8:00 a.m. On hospital day #4, the 8:00 a.m. dose was given at 9:50 a.m., which was 1 hour and 50 minutes later than scheduled.

Zocor (used to control cholesterol) 20 mg by mouth was ordered at bedtime and was scheduled to be given at 10:00 p.m. On hospital day #3 the 10:00 p.m. dose was given at 12:43 a.m., which was 2 hours and 13 minutes after the scheduled time.

Mirtazepine (Remeron -used for depression) 15 mg by mouth was ordered to be given at bedtime and scheduled to be given at 10:00 p.m. On hospital day #3 the scheduled 10:00 p.m. dose was given at 12:43 a.m., which was 2 hours and 43 minutes after the scheduled time.

Arixtra ( used to prevent blood clots) 2.5 mg subcutaneous (under the skin) was ordered to be given daily and was scheduled at 5:00 p.m. On hospital day #3 the scheduled 5:00 p.m. dose was given at 6:30 p.m., which was 1 hour and 30 minutes after the scheduled time.

Neurontin (used to treat seizures but can be used for other neurological disorders) 300 mg by mouth was ordered to be given at bedtime and was scheduled to be given at 10:00 p.m. On hospital day #3 the scheduled 10:00 p.m. dose was given at 12:43 a.m., which was 2 hours and 43 minutes after the scheduled time.

During interview #5 on 4/28/10 at 2:20 p.m. in the administrative conference room, the Chief Nursing Officer (CNO) stated that the medication administration time for the facility was one hour before and one hour after the scheduled medication time. The CNO explained that the nurses used an electronic system called CAREt which monitored and tracked medication administration for the patients. The CNO explained that when the medication was not given within the time frame the medication was scheduled, the nurse was to document the reason. The CNO explained that Clinically Necessary implied that the medication was necessary for the patient. The CNO explained that the Clinically Necessary override had not, however, outlined the specific reason that the medication was not given on time and confirmed that he/she could not identify the reason the medications were given late. The CNO stated that all the nurses were trained on the CAREt system and new nurses were trained during orientation. The CNO explained that equipment malfunction on the CAREt sytem was not addressed in training, however, he/she would address the additional training for nurses concerning reporting and documenting equipment malfunction.