Failure to Assess and Secure Self-Administered Medication
Penalty
Summary
A resident with multiple diagnoses, including GERD, dysphagia, chronic kidney disease, diabetes, hypertension, and atrial fibrillation, was observed on several occasions with two thick white tablets on her overbed table. The resident stated these were gas relief tablets provided by the nurses, which she took after meals. Review of the clinical record confirmed a physician's order for chewable gas relief tablets to be administered as needed. However, the care plan did not indicate that the resident was to self-administer medication or keep medications at bedside, and a prior assessment documented that the resident did not wish to self-administer medications, with staff responsible for administration. Despite this, observations confirmed that the medication was left unsecured in the resident's room on multiple dates. Interviews with an LPN and the Director of Health Services confirmed that the medication should not have been left in the room and that staff were responsible for administering it. The LPN stated she only gave the medication when requested and did not leave it in the room, yet the medication was repeatedly found at the bedside, indicating a failure to follow established protocols for medication administration and security.