Failure to Document Medication Administration and Improper Bedside Medication Storage
Penalty
Summary
Licensed nurses failed to demonstrate competency in medication administration for one resident. Specifically, a nurse did not document the administration, holding, or refusal of a scheduled dose of Lisinopril on the medication administration record (MAR) during a medication pass. The director of nursing confirmed that the facility's policy and procedure requires documentation on the MAR at the time of medication administration, and that this was not followed. Additionally, medication was found left at the bedside of the same resident without a physician's order permitting bedside medication storage. The facility's policies require that medications not be left at the bedside unless there is a written order, and that unused doses be disposed of if not administered. Staff confirmed that the medication was left at the bedside and that this action was not in accordance with facility policy.