Failure to Observe and Monitor Medication Administration
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of practice regarding medication administration for four residents. Specifically, nursing staff did not remain with residents to observe them swallowing their oral medications and, in several cases, left medications at the bedside or in the resident's possession without confirming ingestion. Facility policy and professional guidelines require that staff observe residents taking medications and do not leave medications unattended with residents. For one resident with peripheral vascular disease and malnutrition, a registered nurse handed the resident a cup containing metoprolol and Lyrica, then left the room before confirming the medications were taken. Another resident, admitted for low sodium and post-hip surgery pain, was given Tylenol and sodium chloride tablets; the nurse left the room without ensuring the medications were swallowed. This resident subsequently experienced difficulty swallowing, with water spilling from her mouth and a family member alerting staff to the situation. The nurse only returned after being notified of the issue. A third resident with rheumatoid arthritis was given Tylenol tablets while in bed at a 30-degree angle and eating lunch; the nurse did not reposition the resident upright or observe medication ingestion. For a fourth resident with a cognitive communication deficit, the nurse left a cup of liquid protein solution at the bedside after the resident initially refused it. Staff interviews confirmed that the nurse did not consistently observe residents taking medications and sometimes left medications in the room, contrary to facility policy and professional standards.