Failure to Supervise Medication Administration and Follow Physician Orders
Penalty
Summary
A resident with a history of cerebral ischemia, dysphagia following cerebral infarction, and gastrostomy status was observed self-administering oral medications without staff supervision. The resident, who has a PEG tube, was seen walking out of his room holding a medication cup with approximately four pills, dropping one on the floor, picking it up, and returning it to the cup before ingesting the remaining pills. The resident was not supervised during this process, despite facility policy requiring direct observation during medication administration. The resident's electronic health record did not contain an assessment for self-administration of medications, a care plan for self-administration, or a physician's order permitting self-administration. Further review of the physician's orders indicated that all prescribed medications were to be administered via the PEG tube, not orally. The LPN involved acknowledged that supervision should have occurred and that the resident had not been formally assessed for self-administration. The DON confirmed that the resident was not assessed for self-medication and should have been supervised. Facility policy also specifies that medications must remain under the direct observation of the person administering them during medication pass, which was not followed in this instance.