Failure to Ensure Safe Medication Administration and Physician Orders
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and safe medication administration practices for one resident. A male resident with diagnoses of gastro-esophageal reflux disease and schizoaffective disorder was observed with a cup containing two pills, identified as TUMS, left on his bedside table. The resident stated that the night nurse left the pills for him to take later for heartburn. Review of the resident's records showed no physician order for TUMS, and there was no assessment or care plan intervention allowing the resident to self-administer medications. Interviews with nursing staff, including LVNs and the ADON, confirmed that medications should not be left with residents and that all medications administered must have a physician order. Staff also stated that the resident had not been assessed for self-administration of medications, and there were no instructions or documentation supporting self-administration. The facility's policies require medications to be administered as prescribed and in accordance with physician orders, and only by licensed personnel. The incident was further corroborated by interviews with the DON and Administrator, who both stated that medications should not be left unattended with residents and that staff are expected to ensure residents take their medications before leaving the room. The lack of a physician order for TUMS and the practice of leaving medications at the bedside constituted a failure to meet pharmaceutical service requirements for the resident.