Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of practice for three residents. For one resident with moderate cognitive impairment and a history of mental illness, a licensed nurse left a cup containing eight medications at the bedside, including an antibiotic, vitamins, and other prescribed medications. The nurse did not observe the resident taking the medications and documented administration in the electronic Medication Administration Record before confirming ingestion. The resident was not authorized to self-administer medications, and facility policy prohibits leaving medications at the bedside unless a physician and the interdisciplinary team have determined the resident is capable of self-administration. Another resident, who had undergone cervical spine fusion and was admitted with a cervical disc disorder, was observed wearing a cervical collar. The resident reported being told by nursing staff to always wear the collar per doctor's order. However, the physician's order for the cervical collar had been discontinued, and the surgical incision had resolved with no further treatment ordered. Nursing staff failed to clarify or follow the current physician's order regarding the use of the cervical collar. A third resident with dysphagia and a gastrostomy tube (GT) had a physician's order to check GT placement and flush the tube with water before and after medication administration. During medication administration, a nurse did not check the GT placement or perform a pre-flush as ordered, instead administering the medication without confirming tube position or patency. The nurse acknowledged not following the order and not using a stethoscope to check placement, which was required for the resident's safety. Facility policy requires checking tube placement and flushing before and after medication administration.