Failure to Ensure Proper Management and Documentation of Medications
Penalty
Summary
The facility failed to ensure proper management of over-the-counter (OTC) and controlled medications for its residents. One resident, admitted with multiple diagnoses including epilepsy and aphasia, was observed with a bottle of Tylenol and Nyquil at the bedside; while there was a physician's order for Tylenol, there was no order for Nyquil. The Director of Nursing (DON) confirmed that residents often bring in OTC medications without notifying nursing staff, and in this case, staff did not obtain a physician's order for the Nyquil as required. Additionally, during a medication cart audit, it was found that the narcotic accountability record was missing a required licensed nurse signature, and both an LPN and the DON confirmed that two nurses should have signed the record when accepting or releasing the medication cart.