Failure to Inform Resident of Medication Names and Indications During Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered seven medications to a resident without informing them of the names and indications of each medication prior to administration. The resident, who had diagnoses including type 2 diabetes mellitus and hypertension, was observed swallowing the medications without being told what they were or their purposes. The LVN later acknowledged not providing this information and stated that the resident spoke Spanish, while the LVN did not, and failed to request a translator as required by facility policy. This omission was confirmed during interviews with both the LVN and the Director of Nursing (DON), who stated that the process of informing residents about their medications is essential for resident rights and decision-making. Facility policy and procedures reviewed indicated that staff are required to explain the type of medication being administered and to accommodate residents' communication needs. The failure to inform the resident of the medication names and indications, and to provide translation services, resulted in the resident not being fully informed about their care and not having the opportunity to make choices regarding their medication regimen.