Failure to Safely Administer Medications Without Physician Order
Penalty
Summary
The facility failed to safely administer medications for one resident, as evidenced by clinical record review, observation, and staff interviews. The resident in question had multiple diagnoses, including muscle wasting, dysphagia, a need for assistance with personal care, and hearing loss. According to the resident's assessment, she required help with storing medications securely, administering oral medications, and identifying her medications and their prescribed uses, and she was not approved to self-administer her medications. Despite this, the resident was observed with a cup of medications on her bedside table, and a nurse aide confirmed that these were her morning medications. There was no evidence of a physician's order permitting the resident to self-administer medications, and the Director of Nursing confirmed that such an order did not exist.