Medication Administration Not Performed as Ordered and Medication Left at Bedside
Penalty
Summary
A deficiency occurred when a resident with a history of complete thoracic spinal cord lesion, paraplegia, depression, and urinary retention did not receive medication as ordered. The resident had an intact cognitive status and was not approved to self-administer medications. Physician orders specified that Bethanechol 25 mg, two tablets by mouth three times daily, was to be administered for urinary retention. However, observation revealed two unlabeled medication cups containing crushed and powdered yellow medication left at the resident's bedside. The resident reported that the nurse left the medication earlier and was unaware of its purpose. Further investigation confirmed that the nurse had crushed the Bethanechol without a physician order to do so and left it at the bedside, resulting in the resident not receiving the full dose. The facility's policy required medications to be administered as prescribed, with staff ensuring the full dose is ingested and not left at bedside, especially for residents not approved for self-administration. The DON and the nurse both confirmed that the medication was not administered according to professional standards and facility policy.