Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to follow professional standards of nursing practice in the administration of medications for two residents. For one resident with a diagnosis of muscular dystrophy and dysphagia, the care plan did not include any entry permitting self-administration of medications, and the most recent evaluation for self-administration was completed prior to the diagnosis of dysphagia. Despite this, staff routinely left a cup of medications on the resident's tray table, allowing her to take them at her own pace without direct observation. Facility staff confirmed that, due to the resident's dysphagia, medications should not have been left unattended and should have been administered under direct observation to ensure safety. For another resident with chronic obstructive pulmonary disease (COPD), a registered nurse prepared and administered morning medications, including a Breztri Aerosphere inhaler, which had specific instructions to rinse and expectorate after use. The nurse handed the inhaler to the resident, who self-administered it, but did not instruct or observe the resident to rinse her mouth as directed. When questioned, the nurse was unaware of the requirement to rinse and did not consult the medication administration record or provide further clarification. Facility policies required that medications be administered as ordered, in accordance with professional standards and manufacturer specifications, and that staff refer to drug reference materials if unfamiliar with a medication. In both cases, the facility did not adhere to its own policies or professional standards, resulting in deficiencies in medication administration practices for the two residents.