Failure to Administer and Store Medications According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to administer medication as ordered by a physician for one resident and did not ensure medications were stored in their original packaging prior to administration for five other residents. One resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, was found with a lidocaine patch stuck to her bed linens, dated from the previous day. The nurse responsible had not yet applied the new patch as scheduled, despite documentation indicating otherwise. The medication administration record specified the patch should be applied in the morning and removed at night, but this was not followed, and the nurse's statements conflicted with the documented times. Additionally, during a medication pass, a registered nurse was found to have pre-poured medications for five residents into cups labeled with room numbers, storing them in the medication cart drawer. The nurse stated this was done to expedite the medication pass due to a high resident load. The medications in the cups were scheduled for administration at later times, and the Director of Nursing confirmed that pre-pouring medications is against policy as it could lead to medication errors. Facility policy requires medications to be prepared and administered immediately, with proper documentation at each step, which was not adhered to in these instances.