Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. During the recertification survey, it was observed that medications were left unattended at a resident's bedside. The Licensed Practical Nurse (LPN) responsible for administering the medications did not verify that the resident had taken them before leaving the room and documenting the administration in the Medication Administration Record. The facility's policy requires that the nurse observe the resident taking the medication and document any held or refused medications, which was not adhered to in this instance. The resident involved was cognitively intact and had multiple diagnoses, including anemia, coronary artery disease, renal insufficiency, diabetes mellitus, and malnutrition. The medications left unattended included Ferrous Sulfate, Eliquis, Aspirin, Famotidine, and Vitamin B2. The LPN admitted to placing the medications in the resident's hand and leaving the room without ensuring they were taken. The Registered Nurse Supervisor and Director of Nursing confirmed that medications should not be left at the bedside and that residents must be assessed for self-administration before being allowed to take their own medications.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. Resident # 101 was immediately given the morning medications with no adverse reactions. 2. The DNP assessed the resident since his medication was left at his bedside. There were no ill effects noted. 3. LPN # 4 was given educational counseling, a 1:1 in-service, and written warning on medication administration with proper medication administration techniques and not leaving medication unattended. 4. A medication administration observation was completed with LPN # 4 by the DNS II. II. Identification of Others 1. The facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. On 2/5/2025, the RN Supervisor checked all resident’s rooms on unit 2 AB and no other medications were left unattended at the bedside. 3. On 2/25/2025, the RN Supervisor checked all resident’s MAR indicated [REDACTED]. 4. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director and DNS reviewed the Medication Administration policy and found it to be compliant. 2. All RNs and LPNs will be in-serviced by the DNS/Designee on the above policy with emphasis on administering a full dose of medication to the resident via correct route, offers the resident a drink and observes the resident to ensure medication consumption. Medication should never be left unattended. 3. Lesson plan and attendance sheets will be kept on record for validation. IV. Quality Assurance 1. The Administrator and DNS created an audit tool to ensure that medication was being administered to the resident and not left at the bedside. 2. Audits will be done by the RN Supervisor / Designee on 10 random resident’s room / bedside for medication weekly x 4 weeks, 10 random resident’s room / bedside for medication monthly x 3 months and 10 random resident’s room / bedside for medication quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the DNS. V. The DNS will be responsible for overseeing this corrective action plan by 4/7/2025.