Medication Administration in Dining Room
Penalty
Summary
The facility failed to provide a homelike environment by administering medications to a resident in the dining room during breakfast. A Registered Nurse (RN) administered medications to a resident who was seated alone at a table in the main dining area, preparing to eat breakfast. This action was observed by a surveyor, who noted that there were multiple other residents present in the dining area at the time. The RN acknowledged that the resident was not care planned to have medications administered in the dining room and admitted fault for the oversight. The resident involved had been admitted to the facility with diagnoses including psychotic disturbance, mood disturbance, and anxiety, and had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 06 out of 15. The medications administered, which included calcium, magnesium, and vitamin D supplements, were not ordered to be given with meals. The facility's medication administration policy did not address the administration of medications in the dining room, and the Director of Nursing acknowledged that the practice was incorrect when informed by the surveyor.
Plan Of Correction
Rose Mountain Care Center Facility ID: 315384 Survey Completion date: 12-12-2024 F584 SS-D Safe/Clean/Comfortable/Homelike Environment ELEMENT ONE: It is the practice of the Center to ensure that all residents reside in a safe, clean, homelike environment. The nurse (RN #1) that administered the medication in the dining room to resident #83 was immediately educated on ensuring medication is not administered in the dining room to maintain resident privacy. ELEMENT TWO: The standard was not met for resident #83. All residents who receive medication have the potential to be affected by this deficient practice. ELEMENT THREE: All RN/LPNs were educated on the facilities policy for medication administration, including not administering medication in the dining room. The nursing education was completed by 12/25/24. QUALITY ASSURANCE: To maintain and monitor ongoing compliance, 3 nurses will be med passed monthly by the pharmacy consultant/DON/ADON. In addition, DON or their designee will conduct observation of the dining room weekly x 4 weeks, then monthly x 3 months, then quarterly. Needed corrections will be addressed as they are discovered. Findings to be reported monthly x 12 to Quality Assurance Performance Improvement team for review and action as necessary. Completion date: 12-25-2024