Failure to Ensure Safe Medication Administration and Observation
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, as required by policy, resulting in a medication error rate of 24% (six errors out of 25 opportunities). Observations revealed that a registered nurse (RN) repeatedly did not observe residents swallowing their oral medications. In several instances, the RN dispensed medications into cups, handed them to residents, and left the room without confirming ingestion. For example, one resident was given metoprolol and Lyrica, another was given Tylenol and sodium chloride, and a third was given Tylenol while eating lunch and not properly positioned. In each case, the RN did not remain to ensure the medications were taken as prescribed. Additionally, the RN left a cup of liquid protein supplement with a resident who refused it, instructing the resident to drink it but leaving the room without confirming compliance. Interviews with the RN revealed a lack of understanding regarding the need to observe residents taking medications and uncertainty about how to handle medication refusals. The facility's policy clearly states that staff must observe residents swallowing oral drugs and not leave medications with them, but these procedures were not followed during the observed medication passes.