Failure to Administer and Secure Medications as Ordered
Penalty
Summary
A deficiency occurred when a nurse prepared morning medications for a resident with severe cognitive impairment and multiple diagnoses, including hypertension and hypothyroidism, but failed to administer them. The nurse placed the medication cup, containing a pink and a white pill, on the hallway handrail after being distracted by another resident attempting to get out of bed. The nurse did not return to retrieve or administer the medications to the intended resident. The missed medication was discovered later by another nurse, who found the cup labeled with the resident's room number on the hallway handrail. Upon review, it was confirmed that the resident had not received her prescribed doses of Levothyroxine and Liothyronine, which were ordered for her thyroid condition. The nurse who found the medication noted that he had not been informed of any missed doses and recognized the risk posed by the unattended medication. Interviews with facility staff, including the Unit Manager and DON, confirmed that the nurse responsible for the missed administration acknowledged the error. The nurse stated that he should have returned the medication to the cart before assisting the other resident but failed to do so. Facility policy requires that medications be administered according to the six rights of medication administration and that staff observe residents taking their medications, which was not followed in this instance.