Failure to Follow Medication Administration and Disposal Protocols
Penalty
Summary
Facility staff failed to follow professional standards for medication administration and disposal for two residents. In one instance, a cognitively intact resident with multiple diagnoses, including COPD, alcoholic cirrhosis, diabetes, GERD, and heart failure, was found with two cups containing several pills left at her bedside. The resident reported that the nurse did not want to wake her and left the medications on her overbed table. The resident's care plan noted a history of rejecting and hiding medications. Interviews with nursing staff and the Director of Nursing confirmed that facility policy prohibits leaving medications at the bedside, and staff stated they do not leave medications with residents. In another instance, an LPN was observed disposing of non-narcotic medications refused by a resident into a sharps container rather than the designated Drug Buster disposal system, as required by facility policy. The LPN acknowledged the error during an interview. The DON provided the facility's medication pass procedure, which specifies that all wasted, dropped, or discarded medications must be disposed of in the Drug Buster disposal system. These actions demonstrate a failure to ensure medications were administered and disposed of according to professional standards.