Failure to Accurately Document and Supervise Medication Administration
Penalty
Summary
A resident with a history of cerebral ischemia, dysphagia following cerebral infarction, and gastrostomy status was observed independently taking oral medications from a medication cup without staff supervision. The resident, who had a PEG tube in place, dropped a pill on the floor, picked it up, and returned it to the cup before ingesting the remaining pills. The resident stated he was taking his pills, and there was no staff present to supervise the administration. Interview with an LPN revealed that the resident was given several medications in pill form to take orally, and the LPN acknowledged not supervising the resident during administration. Review of the resident's electronic health record showed no assessment, care plan, or order for self-administration of medications. Additionally, the Medication Administration Record (MAR) inaccurately documented that the medications were administered via PEG tube, contrary to the actual oral administration observed. The Director of Nursing confirmed the inaccuracy in the MAR and stated that documentation should reflect the actual treatment provided.