Failure to Follow Safe Medication Administration Practices
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents by not following safe medication administration practices. For one resident with moderate cognitive impairment and a history of metabolic encephalopathy and cerebrovascular events, a medication cup containing powder with an illegible label was found at the bedside. There was no physician's order or care plan authorizing self-administration of this medication, and staff confirmed that medications should not be left at the bedside. The medication was identified as Zeasorb powder, which was ordered for preventative skin care, but not for self-administration. For another resident, who was cognitively intact and had chronic respiratory and eye conditions, a bottle of Refresh Tears eye drops was found on the bedside table. The resident reported self-administering the drops, but there was no physician's order or care plan for self-administration. Staff acknowledged that the medication should not have been left in the room and that there was no authorization for the resident to self-administer the eye drops. These findings demonstrate a failure to follow facility policy and professional standards regarding medication administration and supervision.