Medications Left Unattended and Incorrectly Documented as Administered
Penalty
Summary
A deficiency occurred when a resident, who was moderately impaired in thought process and dependent on staff for activities of daily living, did not receive their prescribed morning medications as required. The resident had diagnoses including hypertension, osteoarthritis, and pulmonary embolism, and was prescribed medications such as Eliquis, multivitamins, Coenzyme Q10, losartan potassium, and metoprolol. On the day of the incident, a medication cup containing five medications was observed left on top of the resident's breakfast tray, which was parked unattended in the hallway. Both a Licensed Vocational Nurse and a Registered Nurse confirmed the presence of the medication cup and stated that the nurse responsible should have observed the resident taking all medications to ensure proper administration. Despite the medications not being administered, the Medication Administration Record (MAR) was signed by the nurse, indicating that the medications had been given. Interviews with nursing staff and the Director of Nursing confirmed that the MAR should not have been signed unless the medications were actually administered and observed to be ingested by the resident. Facility policy also required staff to observe residents after medication administration to ensure the full dose was taken, and to document any partial ingestion. The failure to follow these procedures resulted in a significant medication error for the resident.