Failure to Ensure Accurate Administration and Secure Storage of Medications
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services that ensured the accurate administration of medications for one resident. The facility's policy requires a licensed nurse to complete a self-administration of medication observation in the electronic health record if a resident requests to self-administer medications. In this case, a resident with Alzheimer's disease and moderate cognitive impairment, as indicated by a BIMS score of 10/15, was assessed and marked as not wanting to self-administer medication. However, the remainder of the assessment was not completed. Despite the assessment indicating the resident did not wish to self-administer, two medications—fluticasone propionate nasal spray and loteprednol etabonate eye drops—were observed left on the resident's over-bed tray table. The resident reported that staff left the medications for her to take and did not always return to collect them, leading her to sometimes bring the medications to the nurse in the hallway. Physician orders specified scheduled administration times for both medications, but the facility did not ensure these medications were administered as ordered or securely stored, resulting in the resident self-administering medications without proper assessment or supervision.