Failure to Discard Unused Liquid Medication Prior to Administration
Penalty
Summary
Staff failed to discard dispensed liquid medication that was not immediately administered to a resident, as observed during medication administration. Specifically, a medication technician prepared and signed out a dose of Lactulose for a resident with severe cognitive impairment, but did not administer it because the resident was asleep. Instead of discarding the medication, the technician returned the open medication cups to the medication cart, covered them with a larger cup, and locked the cart. Approximately 45 minutes later, the same medication was administered to the resident from the previously prepared cups. Interviews with staff confirmed that this practice was not in accordance with facility policy, which requires that medications not immediately administered should be discarded, and that staff should not pre-sign for medications before administration. The incident involved a resident with multiple significant diagnoses, including nonalcoholic steatohepatitis, end stage renal disease, chronic kidney disease, and cirrhosis of the liver.