Failure to Supervise Medication Administration Leads to Resident Hoarding Pills
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The resident, who had diagnoses including schizophrenia, cognitive communication deficit, depression, unspecified dementia, and anxiety disorder, was known to be at risk for medication non-compliance and suicidal ideation. Documentation in the resident's care plan and psychiatric nurse practitioner (NP) notes indicated the need for staff to supervise the resident during medication administration, remain in the room, and verify that the resident swallowed his medications. Despite these documented requirements, the facility did not communicate or implement the necessary supervision for the resident during medication administration. The psychiatric NP's notes from two separate visits indicated that the resident was pocketing medications and required direct observation to ensure ingestion. However, these notes were not properly reviewed or integrated into the resident's care plan or daily practice due to communication lapses, including issues with the facility's fax system and lack of clear responsibility for processing provider notes. As a result, staff were unaware of the need for enhanced supervision, and the resident was able to accumulate 21 pills in his room. The deficiency was discovered when the resident disclosed to a social worker that he intended to use the hoarded medications to commit suicide. The social worker found the medications in the resident's locked bedside table and reported the incident to facility leadership. The resident was subsequently transferred to a psychiatric hospital. The facility did not self-report the incident to the state agency, and there was no evidence of staff in-service training on the specific requirements for medication administration supervision as outlined in the resident's care plan and provider orders.