Failure to Ensure Medication Ingestion and Secure Medication Administration
Penalty
Summary
A resident with vascular dementia, cirrhosis of the liver, and end stage renal disease was observed with a medication cup containing a green liquid left at her bedside while she was eating breakfast. The resident was moderately cognitively impaired and did not know what the liquid was or where it had come from. There was no documented assessment for medication self-administration in her medical record. The medication was later identified as lactulose, which had been ordered to be given twice daily by mouth. Nurse #1, who had administered the medications, initially believed the resident had taken all her medications while the nurse was present. However, it was discovered during an interview that the nurse had left the medication at the bedside and had not ensured the resident had ingested it. Subsequent interviews with the ADON, DON, and Administrator confirmed that medications should not have been left at the bedside and that the nurse should have observed the resident taking all medications before leaving the room.