Failure to Ensure Proper Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and facility policy for one resident. Staff allowed the resident's spouse to administer medications without a physician order, assessment of the spouse's capability, or documentation in the care plan. The spouse reported that he was given the resident's medications by staff and administered them without supervision, and there was no evidence that the physician was notified or that the spouse was properly trained. Staff interviews confirmed that the resident would only take medications from her husband, and that nurses provided the medications to him, sometimes without remaining present to ensure administration. The Medication Administration Record was signed by nurses as if they had administered the medications themselves. The resident involved had diagnoses including protein calorie malnutrition, convulsions, muscle weakness, and required assistance with personal care. The spouse reported concerns about medication administration practices, including medications being given on an empty stomach, a double dose of Keppra, and a missing dose of Eliquis. The Director of Nursing was unaware that the spouse was administering medications and confirmed there was no assessment or documentation to support this practice. Facility policy required medications to be administered by authorized personnel and in accordance with prescriber orders, which was not followed in this case.