Failure to Observe Medication Administration
Penalty
Summary
A resident who was cognitively intact and had multiple diagnoses, including hypertension, anxiety, depression, and respiratory failure, was observed lying in bed with a cup containing five pills and three large chewable tablets on the bedside table. The resident was unaware that her morning medications were present and could not recall how long they had been there. The May 2025 Medication Administration Record indicated that her morning medications included duloxetine, loratadine, calcium, dronedarone, pregabalin, and calcium carbonate. An LPN reported that she had completed the medication pass, provided the resident with her medication cups, and instructed her to take them but did not remain to observe the resident consume the medications. The LPN acknowledged that she should have stayed to ensure the medications were taken. The DON confirmed that facility policy requires nurses to observe residents taking their medications and not to leave medications unattended. The facility's policy also specifies that staff must observe resident consumption of medication.