Failure to Administer Medications as Ordered for Two Residents
Penalty
Summary
The facility failed to administer medications as ordered for two residents, resulting in multiple medication errors. For one resident with severe cognitive impairment, total dependence on staff, and a history of seizures, there were three documented medication errors within a five-week period. These included a missed evening medication and feeding, administration of an incorrect nighttime dose during the morning, and administration of an incorrect nighttime dose. Staff interviews confirmed that medications were forgotten or given in the wrong dosage, and that medication administration was inconsistent, particularly during holiday weekends and when using different medication delivery methods (bottle versus pre-filled syringes). Another resident, who was cognitively intact but physically dependent, had her cup of medications left unattended on a food tray by agency staff. The medications were discovered by kitchen staff after the tray was removed from the resident's room, and subsequently returned to the resident by nursing staff. The facility confirmed that no residents had been assessed as capable of self-administering medications unsupervised, and that nurses were expected to follow the five rights of medication administration.