Failure to Ensure Proper Medication Administration
Penalty
Summary
A resident with a history of stroke and heart failure, and documented moderate cognitive impairment, was not administered medications according to facility policy. The resident reported that a nurse left medications on his bedside table and departed without ensuring the medications were taken. The resident then brought the medications to the night shift supervisor, who confirmed they were not his and disposed of them. The facility's policy requires that medications are not to be left unattended and that staff must observe residents consuming their medications. Interviews with staff confirmed that the resident does not self-administer medications and that it is the facility's expectation for staff to remain with the resident until medications are taken. The Director of Nursing acknowledged awareness of the incident, noting that the medications had been prepared by one LPN and returned to another, with an extra medication found in the cup. However, it was determined that no medication error occurred since the resident did not consume the incorrect medication. The incident demonstrated a failure to follow the facility's medication administration policy.