Failure to Ensure Proper Medication Administration and Monitoring
Penalty
Summary
A deficiency was identified when a resident's prescribed medications were found unadministered in a medication cup on the bedside table, despite being documented as given in the Medication Administration Record (MAR). Observation revealed that the medications, which included Vitamin C, Aspirin, Iron, Gabapentin, a multivitamin with minerals, and Zinc, remained untouched over 90 minutes after the time they were recorded as administered. The resident, who was cognitively intact and alert, stated she had not taken the medications because she was sleeping. The nurse responsible acknowledged placing the medications at the bedside and leaving the room, and confirmed that medications should be administered in the nurse's presence to ensure proper administration and prevent errors. The resident had a history of missed and incorrect medication administration, as documented in multiple care plans addressing missed doses and wrong medications given, with interventions to monitor for adverse effects and notify the medical doctor. Facility policy requires that medications be administered safely and timely, with the MAR only to be initialed after the medication is given. The observed practice of leaving medications unattended and documenting them as administered did not align with facility policy and created a risk for medication errors.