Failure to Administer Medications as Ordered and Lacking Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were administered as ordered for two residents. In the first case, a resident with multiple diagnoses including dementia, diabetes, and chronic kidney disease was found with four assorted pills left on her bedside table, which she identified as her morning medications. She reported that the nurse leaves her medications for her to take at her convenience, but she was unable to identify the pills or their purpose. Review of her records showed no assessment or documentation indicating she was capable of self-administering her medications, nor was there any care plan reflecting self-administration, contrary to facility policy. In the second case, a resident with colon cancer, stroke, and hemiplegia, who is dependent on staff for all care, did not receive a prescribed dose of lisinopril as ordered. The nurse prepared and administered several medications but omitted the lisinopril, which was scheduled for the morning medication pass. The MAR showed the time for lisinopril administration had recently changed, and the nurse was unsure if it had been given. The MAR was not signed for the administration of lisinopril, and the DON confirmed that the MAR should be referenced to ensure all medications are given as ordered. Facility policy requires verification of medications against the MAR prior to administration.