Failure to Ensure Proper Medication Administration and Adherence to Physician Orders
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including peripheral vascular disease, hypertension, alcoholic cirrhosis of the liver, hypothyroidism, and irritable bowel syndrome, was observed experiencing stomach pain while in bed. The resident reported the pain to a CNA, who stated she informed an RN, but the RN denied receiving this information. Upon entering the resident's room, surveyors and the RN found seven oral medications left on the overbed table, with two tablets loose and five in a medicine cup. The RN identified the medications, noting that some were prescribed for gastrointestinal issues, and acknowledged that one medication, atorvastatin, was not prescribed for the resident. A review of the Medication Administration Record (MAR) revealed that the medications left at the bedside, including sucralfate, metoprolol, pantoprazole, levothyroxine, acetaminophen, atorvastatin, and oxycodone, had been documented as administered, despite not being taken by the resident. The facility's policy requires that medications are administered according to physician orders, that nurses verify medication details, and that they observe residents swallowing oral medications. The policy also prohibits leaving medications at the bedside unless the resident is approved for self-administration, which was not the case for this resident. Further review with facility leadership confirmed that the resident had not been evaluated or approved to self-administer medications. Additionally, the administration of a controlled substance (oxycodone) was inconsistently documented, being recorded on the narcotic sheet but not on the MAR. The facility was unable to explain how an unprescribed medication (atorvastatin) was given to the resident, and the medications were not administered in accordance with professional standards or facility policy.