Failure to Secure and Document Medication Administration
Penalty
Summary
Facility staff failed to ensure that medications were properly stored and administered according to policy and professional standards. During an observation, a medication cup containing a red liquid identified as Guaifenesin (Robitussin) was found unattended on a resident's bedside table. The resident reported that the cough medicine was given by a night shift nurse two nights prior. There was no documentation of a self-administration assessment or a provider order authorizing the resident to self-administer medication. Additionally, a loose white pill identified as Sulfamethoxazole and Trimethoprim was found, with no staff able to account for its origin or intended recipient, and no corresponding order in the resident's records for either medication in the preceding three days. Review of the resident's electronic health record confirmed the absence of any provider order or documentation for the administration of cough medication or Sulfamethoxazole and Trimethoprim. Interviews with nursing staff and facility leadership revealed that the nurse who administered the cough medication did not obtain a provider order and failed to document the administration or the need for the medication. Facility policy requires that medications be administered only with a valid provider order, be documented in the Medication Administration Record, and not be left at the resident's bedside. These protocols were not followed in this instance, resulting in the deficiency.