Failure to Inform Resident of Medication During Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate administering of medications to meet the needs of a resident with severe cognitive impairment. Specifically, a medication aide administered Keppra Oral Solution to a non-verbal male resident with a BIMS score of 00, indicating severe impairment, and diagnoses including convulsions, schizophrenia, and a history of traumatic brain injury. The resident's care plan noted impaired cognitive function, non-verbal communication, and a need for staff to monitor and document changes. During medication administration, video footage showed the medication aide entering the resident's room, greeting him, and giving him the medication without advising him of the name or purpose of the medication. The aide ensured the resident swallowed the medication but did not explain what was being administered, despite facility policy requiring staff to explain the administration procedure to residents and adhere to the six rights of medication administration, including explaining the medication to the resident. Interviews with facility staff, including the medication aide, DON, and ADM, confirmed that the resident was not advised of the medication being given. Staff acknowledged that the resident was not cognitively capable of understanding the information, but also recognized that not advising residents of their medications is not appropriate and does not align with facility policy. The deficiency was identified through observation, interview, and record review, and was limited to this resident among those reviewed for pharmacy services.