Unauthorized Medication Administration by Therapy Staff
Penalty
Summary
A deficiency occurred when a therapy director applied an over-the-counter pain patch to a resident without a physician's order and without the administration being performed by a licensed nurse. The resident, who had functional quadriplegia and right leg pain, reported that the therapy director applied the patch after the resident complained of pain during therapy. The patch was observed to be undated, uninitialed, and appeared to have been cut in half at the resident's request. There was no documentation of the patch application in the resident's medical record, and the medication administration record did not reflect an order for the pain patch at the time it was applied. Interviews with staff confirmed that only licensed nurses are authorized to administer medications, including over-the-counter products, and that a physician's order is required. The therapy director acknowledged applying the patch, which was supplied by an LPN, but did not document the administration. The DON confirmed that therapy staff are not permitted to administer medications and that the resident had not been evaluated for self-administration. Facility policy also requires that medications be administered and documented only by authorized personnel in accordance with physician orders.