Failure to Observe Medication Administration
Penalty
Summary
A deficiency was identified when a registered nurse failed to administer medications according to professional standards of nursing practice. During a survey, a resident with diagnoses including spondylosis, depression, anxiety disorder, and chronic pain was found with a cup containing multiple pills left on their overbed table. The resident, who was cognitively intact, stated that the nurse handed them the medication, which they then placed on the table and forgot to take. The nurse confirmed that she did not observe the resident taking the medication and left the room in a rush, deviating from the usual process of watching residents take their medications. Facility leadership, including the Unit Manager and Director of Nursing, stated that the expectation is for nurses to observe residents consuming their medications to ensure proper administration and safety. Review of the facility's policy also confirmed that nurses are required to observe residents taking their medications. The nurse involved acknowledged the importance of this practice and admitted to not following it during the incident.