Failure to Inform Residents of Medications During Administration
Penalty
Summary
The facility failed to inform two residents of the medications being administered to them during medication pass, as required by the facility's policies and procedures. During direct observation, a nurse administered multiple medications to both residents without identifying the medications by name or explaining their purpose and indications. This occurred despite the facility's policy and educational materials, which require that each procedure, including medication administration, be explained to the resident beforehand. One of the residents had a complex medical history, including hypertensive heart disease, iron deficiency anemia, hyperlipidemia, type 2 diabetes mellitus, paranoid schizophrenia, schizoaffective disorder, bipolar disorder, and anxiety disorder. This resident was assessed as having severely impaired cognition and required assistance with activities of daily living. The nurse administered nine different medications to this resident without providing information about the medications prior to administration. The other resident, who was determined to have the capacity to understand and make decisions, was also administered thirteen medications without being informed of their names or purposes. During interviews, the nurse stated that she typically only explained medications if they were new or if the resident was receiving blood pressure medications, believing that long-term residents were already familiar with their medications. However, the Director of Nursing clarified that nurses are expected to identify the name, indication, and possible side effects of medications to residents during administration, especially for those who are alert and oriented. Facility policies and recent in-service education also emphasized the importance of informing residents about their medications as part of ensuring resident rights.