Inadequate Supervision During Medication Administration
Penalty
Summary
The facility failed to ensure adequate supervision during medication administration for a resident, identified as Resident R2. The resident, who has a medical history of kidney failure, hypertension, diabetes, cerebral infarction, and senile degeneration of the brain, was observed with a plastic cup containing approximately four pills on her bedside table. The resident, who was assessed with moderate cognitive impairment and lacked the capacity to make general healthcare decisions, reported that the nurse left the pills for her to take. The Director of Nursing (DON) confirmed that the medications included nifedipine, Allegra, Farxiga, and aspirin, and identified the licensed nurse responsible for leaving the medications unattended. The review of the resident's physician orders indicated that there was no authorization for the resident to self-administer medication. The facility's policy on medication administration requires that medications be administered under the orders of the attending physician or their designees. The incident was discussed with the DON, who acknowledged that the resident's clinical record did not show evidence of authorization for self-administration of medication, highlighting a failure in supervision and adherence to medication administration protocols.
Plan Of Correction
E4 was educated by the DON on the medication administration policy. The DON/designee did an audit of the unit to ensure there were no other residents with medications left at the bedside. Licensed staff were inserviced on the Medication Administration/Disposition policy by the Facility Educator. The DON/designee will conduct random room audits of 10 rooms on each unit to ensure medications are not left at the bedside. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.