Failure to Secure and Supervise Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one resident. Specifically, staff left medications in a resident's room for the resident to take unsupervised, resulting in the resident dropping one Colace pill and one Amlodipine pill on the floor. The facility's policy required that all medications be stored securely and under the direct observation of the person administering them, or locked in the medication storage area or cart during a medication pass. However, this policy was not followed in this instance. The resident involved was a female with multiple diagnoses, including congestive heart failure, generalized edema, myocardial infarction, chronic obstructive pulmonary disease, constipation, and essential hypertension. She had a BIMS score indicating normal cognition. Her medication regimen included Amlodipine and Colace, which were found on the floor of her previous room. The resident reported that staff did not wait for her to take her medication and that she thought she had dropped some pills, noting that staff were in a hurry and she did not have time to ask what she was taking. Multiple staff interviews confirmed that the pills could have ended up on the floor either by the resident spitting them out when staff were not looking or by staff dropping the pills and not picking them up. Staff acknowledged that medications should not be left on the floor and that there was a risk of another resident finding and taking the medication. The facility's policy and staff statements both indicated that medications should always be kept safe and secured, and that medications should not be left unattended in resident rooms.