Failure to Ensure Accurate Medication Administration and Self-Administration Assessments
Penalty
Summary
The facility failed to ensure accurate administration of medication for two residents, resulting in deficiencies related to medication management and adherence to facility policy. For one resident with chronic kidney disease, asthma, hypertension, anxiety, and depression, surveyors observed that medication was left at the bedside in a container of pudding, with 14 pills visible and others disintegrating, hours after the morning medication pass. Staff did not return to check if the medication was taken, yet documented the medications as administered. The resident reported not taking the medications and indicated that staff had not returned to verify consumption. Additionally, expired over-the-counter medications were found at the bedside, and there was no self-administration assessment or care plan authorizing self-administration or bedside storage of medications for this resident, despite a physician's order requiring staff to recheck within an hour. Another resident, with diagnoses including debility, cardiorespiratory conditions, neurogenic bladder, end stage renal disease, hypertension, diabetes, and anxiety disorder, was observed to have medication left at the bedside by a medication technician. Although this resident had a physician's order for unsupervised self-administration and a care plan intervention to assess self-administration ability on admission, quarterly, and with changes in condition, the most recent self-administration assessment was not current, with the last one completed several months prior. Facility policy required quarterly assessments and documentation for residents self-administering medications, which was not followed in this case. Interviews with staff, including the DON and NHA, confirmed that facility policy mandates staff to return and check if residents have taken medications left at the bedside and to complete and document self-administration assessments as required. The failure to observe medication consumption, accurately document administration, and maintain up-to-date self-administration assessments led to the identified deficiencies for both residents.