Failure to Administer Medications per Physician Orders and Facility Policy
Penalty
Summary
Facility staff failed to ensure that medications were administered in accordance with physician orders and accepted professional standards for three residents. During surveyor rounds, multiple instances were observed where medication cups containing various pills were left at residents' bedsides, rather than being administered directly and observed by nursing staff. In each case, the residents had not been assessed or care planned for self-administration of medications, and there was no documentation authorizing self-administration or bedside storage of medications. One resident, with a complex medical history including major depressive disorder, hypertension, diabetes, and cardiac conditions, was found with two medicine cups on her bedside table containing Tylenol, calcium, and a multivitamin. She reported that she did not want all the prescribed Tylenol and would dispose of unwanted pills herself, indicating that staff routinely left medications for her to take at her discretion. Review of her Medication Administration Record (MAR) showed that nurses had documented administration of these medications, despite the resident's statements and the physical evidence that the medications had not been taken as ordered. Another resident, with diagnoses including hypertension, chronic pain, and psychosis, was found with a medicine cup containing several tablets and multiple bottles of eye drops, one of which was expired. The resident was unable to provide details about the medications or how long they had been at her bedside. A third resident, with a history of restless leg syndrome, anemia, and diabetes, was observed with a medicine cup containing many pills, which she ingested only after being prompted by the surveyor. In all cases, the facility's own medication administration policy required that medications be administered at the time they are prepared, that the nurse observe the resident swallowing the medication, and that self-administration be authorized and care planned, none of which were followed for these residents.