Failure to Ensure Safe Medication Administration and Competency of Nursing Staff
Penalty
Summary
Nurses and nurse aides failed to ensure that residents took their medications as intended, resulting in multiple incidents where medications were left at the bedside or taken by the wrong resident. In one case, a cognitively intact resident with a history of brain dysfunction and dementia took another resident's seizure medications after they were left unattended in her room. The incident report and interviews revealed that the nurse did not observe the resident swallowing the medication, and the care plan did not address the risk of such an event. There was also no documentation of the incident in the resident's progress notes for the month. Another resident, who was severely cognitively impaired and had a seizure disorder, was given his medications by a nurse who did not ensure he swallowed them. Instead, the resident took the medication cup to another resident's room, where the medications were subsequently ingested by the wrong person. The care plan for this resident did not address the need for staff to observe medication administration or swallowing, and there was no documentation of the incident in the progress notes. Staff interviews confirmed that the nurse was unfamiliar with the resident's routine and did not follow the facility's policy to observe the act of swallowing. Additionally, a resident with moderate cognitive loss and COPD was observed with an albuterol inhaler at the bedside without a documented assessment or order permitting self-administration. Staff interviews indicated inconsistent practices regarding leaving medications at the bedside, and the resident's records lacked a self-medication administration assessment. Another cognitively intact resident was found with multiple pills left on her overbed table, and staff confirmed that medications should not be left in resident rooms. Facility policy required staff to observe residents swallowing medications and prohibited leaving medications at the bedside, but these procedures were not consistently followed.