Failure to Ensure Direct Observation of Medication Administration
Penalty
Summary
A deficiency occurred when a medication aide (MA) failed to ensure a resident took her prescribed medications during a medication pass. The aide entered the resident's room, handed her a medication cup, and was told by the resident that she would take the medication later. Despite this, the aide instructed the resident to take the medication immediately but then left the room before confirming that the medication was actually taken. Video evidence confirmed that the aide left the medication at the bedside and exited the room prior to the resident ingesting the medication. The resident involved was a cognitively intact female with multiple diagnoses, including COPD, diabetes, hypertension, peripheral vascular disease, and congestive heart failure. Facility records indicated that the resident had impaired visual function and required assistance with activities of daily living. The facility's medication administration policy required staff to observe residents taking their medications and to monitor for adverse effects, contraindications, and effectiveness, which was not followed in this instance.