Failure to Ensure Proper Medication Administration and Documentation
Penalty
Summary
A deficiency occurred when nursing staff failed to follow professional standards of medication administration for a resident with multiple neurological and cognitive diagnoses, including encephalopathy, vascular dementia, and spastic hemiplegia. The resident required staff supervision and cueing due to moderate cognitive impairment. During an observation, a medication cup containing three white tablets and one brownish capsule was found on the resident's bedside table, which was later identified as Baclofen and Valerian root. The medications had been documented as administered in the resident's medication administration record (MAR), despite the fact that the resident had not taken them. Record review showed that the resident did not have an assessment for self-administration of medications, and care plans required staff to administer medications as ordered and provide necessary cues due to cognitive impairment. Interviews with the DON and nursing staff confirmed that the nurse responsible had left the medications at the bedside after unsuccessfully attempting to wake the resident, intending to return but failing to do so. The nurse had documented the medications as given in the MAR without observing the resident swallow them, contrary to facility policy and professional standards. Further interviews revealed that staff were aware of the correct procedures, which included staying with the resident until medications were swallowed and documenting only after administration. The DON confirmed that the nurse did not follow these procedures and that there was no documentation of medication refusal or self-administration capability for the resident. The incident was identified during a survey, and the facility's policy was clear that medications should not be left at the bedside and must be administered and documented accurately.