Failure to Administer Complete Medication Dose
Penalty
Summary
A resident with diagnoses including diabetes mellitus, rheumatoid arthritis, and dementia was admitted to the facility and had multiple physician orders for medications such as hydroxychloroquine, vitamin C, memantine, metformin, multivitamin-mineral, prednisone, and senna. The resident was assessed as rarely or never able to express ideas or understand others and was dependent on nursing staff for daily activities. During a medication pass, an LVN crushed and administered the resident's medications, but did not ensure the full dose was given, as some medication remained in the medicine cups after administration. The LVN confirmed that the resident did not receive the complete dose of the prescribed medications, which was also acknowledged by the DON. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not followed in this instance. The failure to administer the full dose of medication was directly observed and confirmed through staff interviews and record review.