Failure to Ensure Proper Medication Administration
Penalty
Summary
A deficiency occurred when a resident with intact cognition was observed taking medication at the medication cart without a nurse present to ensure the medication was swallowed. The resident's physician order sheet did not document a focus for self-administration of medication, and there was no evidence of a physician's order, resident education, care plan, or assessment for self-administration. The resident reported that the LPN handed her the medication and then walked away for a few seconds, during which time the resident took the medication and drank water without supervision. The LPN confirmed she did not observe the resident take the medication because she was multitasking. The Director of Nursing stated that self-administration of medication requires specific interventions for safety, including a physician's order and assessment, and that nurses are required to observe residents to ensure medications are swallowed. Facility policy requires medications to be administered in accordance with good nursing practices and only by authorized personnel, with sufficient staff and systems in place to ensure safe administration without unnecessary interruptions.