Failure to Ensure Proper Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure proper medication administration and monitoring for two residents. In one instance, a female resident with severe cognitive impairment and a diagnosis of dementia was observed with partially dissolved pills falling from her mouth nearly two hours after the morning medication pass. The registered nurse who administered the medication stated that they believed the resident had swallowed all her pills but did not check for pocketing after administration. Both the LPN and the VP of Operations confirmed that nurses are expected to ensure residents have swallowed their medications as part of the administration process. The facility's policy requires medications to be administered safely, timely, and as prescribed. In another case, a resident was found with multiple bottles of medications, including nasal sprays and eye drops, at her bedside over consecutive days. The LPN and DON both stated that residents must have an order and be assessed for the ability to self-administer medications and keep them at the bedside, which had not been done for this resident. The resident's physician orders did not include permission for self-administration or bedside storage of these medications, and there was no order for one of the medications present. The facility's policy specifies that self-administration must be approved and assessed by the attending physician and treatment team.