Failure to Document Site of Nasal Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with its own medication administration policy, specifically regarding the documentation of the route and site of administration for inhaled medication. A resident with a diagnosis of allergic rhinitis had a physician's order for calcitonin nasal spray to be administered in alternating nostrils daily. During a medication pass, an LPN was observed administering the nasal spray into the resident's right nostril and documenting the administration, but did not record which nostril was used. Upon interview, the LPN stated that staff previously documented the nostril used but had stopped doing so, relying instead on memory. The Director of Nursing confirmed that staff are expected to document the site of administration and was unaware that this was not being done.