Failure to Ensure Safe Medication Administration and Storage
Penalty
Summary
A deficiency occurred when a resident with a history of schizophrenia, dementia, anxiety, depression, delusions, hallucinations, and bipolar disorder was found with a moistened ibuprofen tablet stuck to her gown. The resident had a BIMS score indicating moderately impaired cognition and a care plan noting impaired decision-making due to delusional thought processes. Her self-administration assessment indicated she did not wish to self-administer medications, and all medications were to be administered by staff and kept in the nurses' cart. Despite these precautions, during an observation, the resident was found with a pill on her gown, which she did not recognize. An LPN confirmed the pill was ibuprofen, which matched the medication order and administration record. The LPN stated the pill likely fell out of the resident's mouth during administration by the night nurse. The facility's policy required staff to ensure medications were not left at the bedside unless authorized, and the DON stated nurses should watch residents to ensure all pills are swallowed.