Failure to Administer and Monitor Medications per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders and facility policy for two residents. For one resident with diagnoses including type II diabetes mellitus, respiratory failure, and chronic kidney disease, medications were not administered at the scheduled times, and a medication cup containing three tablets was found at the bedside after the nurse had documented administration. The resident reported that medications were sometimes given late and that staff did not observe her taking them. The nurse confirmed leaving the medications at the bedside without witnessing ingestion and documented them as administered. Additionally, the facility did not complete a Self-Administration of Medication Observation Assessment for this resident upon readmission, as required by policy. The Director of Nursing confirmed that medications should not be left at the bedside and that nurses must witness administration, stating that any refusal or delay should be documented and the physician notified. The facility's policy requires medications to be administered in accordance with orders and within the required time frame, and only allows self-administration if the care team determines the resident is capable. For a second resident with hemiplegia, acute respiratory failure, and diabetes, multiple medications scheduled for administration at a specific time were instead given over two hours late. The Director of Nursing reviewed the records and confirmed the late administration, reiterating the requirement for timely medication administration per physician orders. These findings were based on observation, interview, and record review.