Failure to Ensure Safe Medication Administration and Adherence to Self-Administration Policy
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were administered as ordered for three residents. One resident with multiple diagnoses, including osteoarthritis and dysphagia, was observed self-administering a cup of assorted pills at lunch without any nurse present. The resident stated that he usually takes his noon medications by himself in the dining room. Another resident with conditions such as rhabdomyolysis, hypothyroidism, and dementia was found with a medication cup containing an orange fluid on his bedside table, which he identified as his blood pressure medication. He reported that the nurse leaves the medication with him, and he takes it when he feels like it. A third resident with a history of cystitis, dementia, diabetes, and kidney transplant was found alone in her room with a tube of topical arthritis pain cream on her bedside table. An LPN acknowledged that the resident was not supposed to have the cream in her possession and that it should be kept in the medication cart. Additionally, an unidentifiable white pill was found on the counter in the group dining room, within easy reach of residents. The Assistant Director of Nurses identified the pill as acetaminophen but was unsure how it ended up there. Interviews with nursing staff and review of records revealed that no residents on the unit were assessed or care planned for self-administration of medications, despite facility policy requiring an interdisciplinary team assessment and care plan documentation before allowing self-administration. The Director of Nurses confirmed the absence of such assessments or care plans for the involved residents.