Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
A deficiency was identified when a resident did not receive their scheduled morning medications as prescribed. The resident was observed with a cup of pills left on the bedside table, stating that he could not take his medications because crackers, which he uses to take his pills, were not available. The responsible nurse confirmed that the medications were not administered due to the absence of crackers. However, a review of the electronic medication administration record showed that the nurse had already signed out the medications as administered, despite the resident not having taken them at that time. Further review revealed that the facility's policy requires medications to be documented as administered only after they are given, and any withheld or refused medications must be documented accordingly. The nurse's competency record indicated understanding of this protocol, but the staff orientation and training checklist for the nurse was incomplete. The resident's care plan also noted a history of medication refusal, which was not appropriately addressed in this instance. These findings demonstrate a failure to ensure that nursing staff followed established protocols for medication administration and documentation, compromising the resident's well-being.