Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medication according to professional standards of practice for a resident, identified as R12. On April 1st, R12 was observed with a full breakfast tray and a small cup containing approximately 10 pills. R12, who was alert but unable to explain the presence of the pills, had a recent BIMS score indicating intact cognition and a court-appointed guardian. Nurse E, responsible for R12, initially believed the resident had taken the medication and later asked R12 to take the pills without providing their names. The clinical record showed no order allowing R12 to self-administer medication. Nurse E documented in the Medication Administration Record (MAR) that the medications were administered at 8:36 AM, despite the pills being observed untouched and dry on the tray at 10:03 AM. The Director of Nursing (DON) confirmed that Nurse E should not have left the medications with the resident and should not have recorded them as administered without witnessing their consumption. The medications included Jardiance, Duloxetine, Metoprolol, Zyrtec, Atorvastatin, Glipizide, Ferrous Sulfate, and Depakote, which were critical for managing R12's conditions such as diabetes, depression, high blood pressure, and anemia.