Failure to Implement Person-Centered Care Plan for Medication Administration
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames to meet a resident's medical and nursing needs. The resident, an older adult male with a history of left middle cerebral artery stroke, urinary tract infection, and metabolic encephalopathy, was dependent on a PEG tube for nutrition, hydration, and medication administration due to dysphagia and unsafe oral intake. The care plan clearly indicated that all medications were to be administered via the PEG tube, and that the resident was not safe for oral intake of food or medications. Despite these documented requirements, a certified medication assistant (CMA) administered oral medications to the resident, placing pills in his mouth for him to swallow. The resident reported this incident, stating that he was supposed to receive medications through his PEG tube per physician orders. Interviews with staff confirmed that the CMA did not review the care plan or medical record before administering the medications, resulting in the resident receiving medications by an incorrect route. The nurse practitioner and other staff confirmed that the medication given was not prescribed to the resident and that the error occurred due to failure to follow the care plan and medication orders. The facility's policy required all medication staff to verify the physician's orders and the resident's care plan before administering any medications. Multiple staff interviews confirmed that the care plan was not followed, and the CMA responsible initially denied the error before admitting to it during the investigation. The incident was reported by other staff members, and the resident was monitored for complications following the medication error. The deficiency was attributed to the failure of staff to review and implement the resident's care plan as required.