Failure to Ensure Safe Medication Administration for Resident Without Self-Administration Order
Penalty
Summary
Staff failed to ensure the accurate and safe administration of medication for one resident with moderate cognitive impairment and a history of refusing medications. On the morning of the survey, medication was observed on the resident's bedside table hours after the scheduled administration time, despite documentation indicating the medication had been given. The resident reported that staff left the medication for self-administration, but the resident forgot to take it. The resident's medical record did not contain a current physician's order or assessment authorizing self-administration of medication, and a previous assessment indicated the resident should not have medications left at bedside due to a tendency to forget or mishandle them. Interviews with staff revealed inconsistent practices regarding medication administration. The medication technician who documented administration could not explain why the medication was found in the resident's room or why the resident reported being left to self-administer. Another LPN confirmed that leaving medication at bedside was not permitted for this resident, as the resident was not assessed as capable of self-administration. The facility's policies require staff to remain with residents until medication is swallowed and prohibit leaving medication in a resident's room without proper assessment and orders, which were not followed in this instance.