Failure to Ensure Proper Administration and Documentation of Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cerebral palsy, hypotension, and heart failure did not receive their midodrine HCl 10 mg tablet as prescribed. The physician's order required the medication to be administered three times daily for hypotension, and the care plan reflected this intervention. On the day in question, the medication was documented as administered at 11:08 a.m., two hours after it was actually given at 9:08 a.m. During an observation, a white round pill identified as midodrine was found on the hallway floor outside the resident's room. The Director of Staff Development confirmed the pill's identity and noted that the nurse should ensure residents swallow their medications. Further review of the Medication Administration Record (MAR) with the LVN revealed that the medication was marked as not given, despite the bubble pack for that dose being empty. The LVN stated he believed he had given the medication with applesauce but acknowledged that documentation should occur before moving to the next resident. The facility's policy required medications to be administered and documented in a safe and timely manner, with the MAR initialed after each administration and before proceeding to the next medication. The failure to ensure the medication was properly administered and documented constituted a significant medication error.