Failure to Inform Resident About Medication During Administration
Penalty
Summary
The facility failed to ensure that a resident was fully informed about her medication during administration. On two separate occasions, nursing staff prepared and administered the powdered medication Lokelma to a resident with diagnoses including high blood pressure, diabetes, and Bell's palsy. During both medication passes, the staff did not inform the resident about the name or purpose of the medication. The resident expressed difficulty consuming the medication due to its taste, gagged, and became visibly upset, but was only encouraged to finish the dose without any explanation or education provided. Record review showed that the resident was moderately impaired for daily decision making, and a physician's order was in place for daily Lokelma administration for high potassium. Interviews with staff confirmed that the expectation was for nurses and medication aides to inform residents about their medications prior to administration. The facility's medication administration policy also required staff to provide residents with information about the drugs they were receiving.