Late Medication Administration, Improper Disposal, and Inaccurate Documentation
Penalty
Summary
A Licensed Nurse failed to follow facility policy and professional standards by administering a resident’s scheduled medications four hours late, improperly disposing of a refused medication, and inaccurately documenting medication administration. The nurse gave the resident her 8 a.m. and 9 a.m. medications at 1:40 p.m., and when the resident refused MiraLAX, the nurse disposed of it in the trash instead of using the designated drug disposal system. The nurse then documented in the Medication Administration Record (MAR) that all medications, including the refused MiraLAX, were given at the scheduled times, rather than reflecting the actual time of administration and the refusal. The resident involved had a medical history including rhabdomyolysis, bariatric surgery status, and hypomagnesemia, and was admitted in January 2025. Facility leadership, including the DON and ADON, confirmed that the nurse did not follow physician orders, failed to notify the physician of the refusal, and did not adhere to the facility’s medication disposal policy. Review of the MAR and interviews confirmed the discrepancies in documentation and medication handling.
Plan Of Correction
Services Provided Meet Professional Standards Corrective Action(s): On 04/24/2025, LN 1 had a discussion with Resident 1 regarding her medication time preferences and notified the physician, resulting in a change to the medication administration schedule. On 04/24/2025, the Assistant Director of Nursing initiated an eLenteract CIC to evaluate Resident 1 for any undesired effects of medications that were not given timely and notified the physician. On 04/24/2025, the Director of Nursing re-educated LN 1 regarding the Policy and Procedure of Physician Orders, Discarding and Destroying Medications, Administering Medications, Medication Errors, and Nursing Documentation. Identification of other residents at risk: On 04/24/2025, the Assistant Director of Nursing checked if any other residents did not receive medications at the scheduled time, and no other residents were affected by this deficiency. Systemic Changes: On 05/08/2025, the Director of Staff Development will re-educate staff regarding the Policy and Procedure of Physician Orders, Discarding and Destroying Medications, Administering Medications, Medication Errors, and Nursing Documentation. The Director of Staff Development or designee will weekly skills check the Licensed nurses for Medication Observation Pass, including discarding and destroying medications, until competency is met. Monitoring: The Director of Staff Development or designee will report the results of the Licensed Nurses' skills checks for Medication Observation Pass, including discarding and destroying medications, to the Director of Nursing for further intervention if needed. The Director of Staff Development will report the findings and trends of the Medication Observation Pass, including discarding and destroying medications, to the QAPI committee monthly for three months or until compliance is met. Compliance Date: 05/08/2025