Failure to Ensure Proper Medication Administration and Documentation
Penalty
Summary
A deficiency occurred when a nurse failed to observe a resident consume medications at the time of administration and left medications unattended in the resident's room. The nurse brought the medications into the room while the resident was in the bathroom and, instead of waiting, left the medications in the room and trusted the resident would take them. Upon returning about an hour later, the nurse discovered the medications had not been taken. The nurse later confirmed this action during an interview and in a written statement. Additionally, after an incident involving the resident's daughter, the nurse was removed from direct care of the resident but continued to pull medications from the medication cart while another nurse administered them. Despite not administering the medications herself, the nurse signed the Medication Administration Record (MAR) as if she had administered the medications. The facility's policy requires the individual who administers the medication to verify the correct resident, medication, dosage, time, and route, and to sign the MAR only after giving the medication. These actions were confirmed by both the nurse and the Director of Nursing.