Unauthorized Administration of Sleep Aids and Antihistamines by LPN
Penalty
Summary
A deficiency was identified when a facility failed to protect residents' rights to be free from abuse by allowing an LPN to willfully administer unauthorized over-the-counter medications, specifically Melatonin and Benadryl, to multiple residents during the night shift. The facility's policy prohibits the use of chemical restraints or medications for staff convenience or discipline without a provider order. Despite this, the LPN was found to have given these medications to residents without physician orders, as confirmed by medication counts, staff statements, and resident interviews. Several residents exhibited changes in behavior and cognition that coincided with the nights the LPN worked. For example, one resident became significantly more confused, another was excessively drowsy and unable to walk, and others displayed increased aggression or changes in activity participation. Staff and residents reported these changes, and documentation confirmed that the medications administered were not ordered for these individuals. The facility's investigation substantiated the allegations, with multiple staff overhearing the LPN discuss giving these medications and observing the resulting behavioral changes in residents. The affected residents had various diagnoses, including dementia, anxiety, insomnia, and a history of falls. Some were cognitively intact, while others had severe cognitive impairment. The unauthorized administration of medications was not isolated to a single resident but involved at least five individuals, with the exact number undetermined. The DON confirmed that both Melatonin and Benadryl were stock medications and that the LPN administered them without proper orders, violating residents' rights and facility policy.
Plan Of Correction
I have enclosed the Plan of Correction for the above-referenced facility in response to the Statement of Deficiencies. While this document is being submitted as confirmation of the facility's ongoing efforts to comply with all statutory and regulatory requirements, it should not be construed as an admission or agreement with the findings and conclusions in the Statement of Deficiencies. F: 600 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? On 7/9/25, Nurse A was suspended pending investigation related to the administration of Melatonin and Benadryl. Nurse A resigned on 7/15/25. Resident 999 was evaluated by a licensed nurse on 7/11/25, and notified the Healthcare Provider (HCP), and the resident's representative of the medication error. No new orders were obtained. Resident 900 was reviewed on 7/11/25 by the Director of Clinical Services (DCS) and/or Assistant Director of Clinical Services (ADCS) for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the med error. No new orders were obtained. Resident 850 was reviewed on 7/11/25 by the Director of Clinical Services and/or Assistant Director of Clinical Services for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 825 was reviewed on 7/11/25 by the Director of Clinical Services and/or Assistant Director of Clinical Services for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 800 was reviewed on 7/11/25 by the Director of Clinical Services and/or Assistant Director of Clinical Services for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 7/9/25, the DCS or designee reviewed current resident records to determine if they had physician orders for Melatonin and Benadryl. Between 7/10/25 and 7/15/25, current residents' records and associate interviews were reviewed by the DCS and ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. On 7/15/25, current residents with a BIMS of 12 or higher were interviewed by Social Services or designee regarding medications and if they were offered sleep medications. No further residents were identified. Between 7/10/25 and 7/15/25, eight (8) family members were interviewed by the Executive Director or designee for any concerns in care, medications, or changes in their loved one. What measures will be put into place or systematic changes made to ensure that the deficient practice will not recur? On 7/18/25, the Assistant Director of Clinical Services provided re-education to licensed nurses on Melatonin and Benadryl administration, 7 rights of medication administration, physician notification on missed/refused medication, PRN medication administration, abuse, and neglect. On 7/8/25, Melatonin was counted by the DCS or designee. Upon further staff interviews, on 7/9/25, daily Melatonin counts expanded to all nurse carts, and daily Benadryl counts were added. On 7/28/25, the DCS or designee changed the Melatonin and Benadryl from stock bottles to individual bubble cards filled through the pharmacy. Social Services and/or designee will review the Behavior Report in Daily Stand Up to assist with identification of new changes in residents' behaviors that may require an additional review. How will the facility monitor its performance to make sure that solutions are sustained? To assist with compliance, the DCS or designee has audited the count for melatonin, daily beginning on 7/8/25. The DCS or designee has audited daily the count for Benadryl beginning on 7/9/25. Daily audits continued through 7/27/25 with no discrepancies noted. Audits will be conducted twice a week for two weeks, then weekly for a combined total of 12 weeks. Social Services or designee will conduct two resident interviews weekly with residents BIMS 12 or higher for 12 weeks. The Assistant Director of Clinical Services or designee will conduct one medication pass observation per week for 12 weeks. The DCS or designee will review findings of the audits monthly in the Quality Assurance Performance Improvement (QAPI) Meeting for 3 months. Discipline Responsible: The Director of Clinical Services or designee will be responsible for compliance.