Failure to Ensure Complete Medication Administration and Accurate Documentation
Penalty
Summary
The facility failed to ensure that medications were completely administered and accurately documented for one resident. The resident, who was cognitively intact and had diagnoses including adrenocortical insufficiency, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, and hypertension, was care planned for non-compliant behavior related to medication administration. On the day in question, the resident's Medication Administration Record (MAR) indicated that all morning medications were administered and signed off by an LPN, but the resident did not actually take the medications at the scheduled time. According to progress notes and interviews, the LPN left the resident's medications in her room, intending for her to take them on her own. When the nurse returned later, the medications were still present, along with a pill from the previous night. The nurse then removed the medications, refused to allow the resident to take them late, and documented the situation in a progress note. The resident and her daughter both reported that the medications were not taken as scheduled and that the nurse did not ensure ingestion or consult the physician about late administration, despite the importance of the medications for the resident's conditions. Facility policy required that medications be administered at the time they are prepared, with the nurse observing ingestion and documenting administration immediately afterward. The nurse's actions did not comply with this policy, as medications were left at the bedside without an order, ingestion was not observed, and the MAR was signed as if the medications had been given. The nurse also did not consult the physician regarding the possibility of late administration, despite the resident's medical needs.