Failure to Observe Medication Administration by Licensed Staff
Penalty
Summary
A licensed vocational nurse (LVN) failed to provide pharmaceutical services in accordance with facility policy by not remaining in the room to observe a resident taking prescribed oral medications. The LVN entered the resident's room with a cup containing pills, which was handed to the resident's family member, who then administered the medications to the resident one by one. While the family member was still administering the last two pills, the LVN left the room to return to the medication cart, without confirming that all medications had been taken. The LVN later acknowledged that she should have stayed in the room to ensure all medications were administered and that the metformin pill was still in the cup when she left. Interviews with the unit manager and the director of nursing (DON) confirmed that nurses are required to follow the five rights of medication administration and must observe residents taking their medications to completion. The facility's medication administration policy also specifies that staff must observe the client taking the medication. The resident involved had multiple diagnoses, including spinal stenosis, hypertension, diabetes mellitus, and anxiety disorder. The care plan did not address medication administration, and the resident's BIMS score was not completed at the time of the incident.