Failure to Ensure Resident Swallowed Oral Medications During Administration
Penalty
Summary
A deficiency occurred when a medication aide (MA) failed to ensure that a resident with severe cognitive impairment and a history of medication refusal and pocketing actually swallowed her prescribed oral medications. The aide placed the medications in the resident's mouth during breakfast and left the area without verifying ingestion. The medications were later found in a cup beside the resident's breakfast tray by a family member, who then assisted the resident in taking them. The resident involved had diagnoses including Alzheimer's disease, coronary artery disease, hypertension, and major depressive disorder, and was assessed as having severe cognitive impairment. She was prescribed multiple medications, including antidepressants, anticoagulants, diuretics, antiplatelets, and anticonvulsants. The medication administration record indicated that the medications were documented as given, but direct observation and interviews revealed that the aide did not remain with the resident to confirm that the medications were swallowed, despite knowing the resident's history of holding or refusing medications. Interviews with facility staff confirmed that the standard procedure for medication administration requires the staff member to remain with the resident until all medications are taken and to check the resident's mouth if there is a history of pocketing. The aide admitted to not following this procedure and acknowledged awareness of the correct protocol. The incident was reported by the resident's family member, and staff interviews corroborated that the medications were left unsupervised, leading to the deficiency in pharmaceutical services.