Failure to Monitor Medication Consumption During Administration
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, left-sided weakness, dysphagia, and dementia was not properly monitored during medication administration. The resident had physician orders allowing medications to be crushed unless contraindicated and had an as-needed order for acetaminophen for pain. During an observation of wound care, the resident exhibited non-verbal signs of pain, prompting a nurse to instruct another nurse to administer pain medication as ordered. The nurse returned with crushed medication mixed in applesauce and administered it to the resident, then exited the room without confirming that the medication was swallowed. A registered nurse who remained in the room observed that the resident had not swallowed the medication and proceeded to manually massage the resident's throat to stimulate swallowing. The registered nurse stated that the nurse who administered the medication should have stayed to ensure the medication was swallowed before leaving the room. This failure to monitor medication consumption resulted in non-compliance with ensuring safe medication administration for the resident.