Failure to Ensure Direct Supervision of Medication Administration
Penalty
Summary
Staff failed to adhere to professional standards of care by not ensuring that medications were taken by four observed residents at the time of administration. Specifically, medications were left unattended on dining tables for residents with moderate cognitive impairment, and staff did not confirm ingestion before leaving. In one instance, a resident with moderate cognitive impairment had a medication cup with pills left in front of her for over 30 minutes before the cup was found empty, without staff confirming the medication was taken. Another resident received a powdered supplement in thickened juice, but the powder was not fully dissolved and remnants were left in the cup after the resident had mostly finished the drink. Additionally, a resident picked up a pill from the floor and ingested it without staff supervision, and another resident with moderate cognitive impairment drank an unknown clear substance from a medication cup left on the table, not knowing what it was. Review of medical records showed that none of these residents had a physician's order or assessment supporting their ability to self-administer medications. Interviews with the unlicensed medication aide and LPN confirmed that they left medications on tables without ensuring ingestion, contrary to facility policy and the DON's expectations. The facility's policy required direct observation of medication administration and prohibited leaving medications unattended unless a self-administration assessment and physician's order were in place.