Failure to Follow Resident Medication Administration Preferences Resulting in Distress
Penalty
Summary
A deficiency occurred when a nurse failed to follow a resident's stated preference and clinical record instructions for medication administration. The resident, who was cognitively intact and diagnosed with Parkinson's Disease, informed the nurse that he takes his pills one at a time on a spoon. Despite this, the nurse placed all of the resident's pills in his mouth at once, leading to a coughing episode, watery eyes, and a runny nose. The nurse did not remain with the resident to assess his condition and dismissed concerns raised by a nurse aide, refusing to check on the resident after the incident. The resident continued to experience distress until another staff member intervened and a registered nurse assessed him. The incident resulted in a downgrade of the resident's diet and a referral to speech therapy. Interviews confirmed that the nurse's actions caused both physical and emotional distress to the resident and that the nurse failed to report the incident or seek appropriate assessment for the resident after the adverse event.