Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with a history of seizure disorder, hypertension, and peripheral autonomic neuropathy did not receive their prescribed evening medications, including an anticonvulsant, Tylenol, and cold medication. The resident reported that the medications were left on her tray table while she was asleep, and she was not awakened to take them. The following morning, the resident informed a nurse that the medications were still in her room and had not been taken. The Assistant Director of Nursing confirmed that the medications, including the seizure medication, were left in the resident's room and should not have been left for the resident to self-administer. Review of the Medication Administration Record showed that the medications were incorrectly documented as administered, and a follow-up was falsely recorded as effective for the as-needed cold medication. Interviews with nursing staff confirmed that the nurse responsible for the previous evening's medication round did not follow proper procedures for medication administration and documentation. Facility policy requires accountability in the medication system, which was not followed in this instance.