Failure to Ensure Safe Medication Administration and Monitoring
Penalty
Summary
A deficiency occurred when a resident with diagnoses of paranoid schizophrenia and anxiety disorder, who had moderately impaired cognition and a history of hallucinations and delusions, was found in possession of two medications—Klonopin and Risperdal—without staff knowledge. The resident was observed in the hallway holding a green pill (Risperdal) and a yellow pill (Klonopin), which matched the medications prescribed to him. The resident admitted to keeping the medications after they fell to the floor on an unknown date and requested that staff not be informed. Review of the Medication Administration Record indicated that both medications were scheduled to be administered in the morning, but the resident had not received the full dose as intended due to pocketing the pills. Interviews with nursing staff revealed that the resident had a known tendency to pocket medications rather than swallow them, and that staff were responsible for ensuring the resident swallowed each pill before moving on. The Director of Nursing confirmed that failure to observe the resident swallowing the medications resulted in the resident not receiving the correct dose, and that this practice was not in accordance with the facility's policy for safe medication administration. The incident also created the potential for other residents to access medications not prescribed to them.