Failure to Ensure Competent Medication Administration and Documentation
Penalty
Summary
The deficiency involves failures in nursing staff competency related to medication administration for two residents. Facility policy for administering oral medications, revised April 2019, requires staff to remain with the resident until all medications have been taken. For one resident, admitted on 06/03/2022 with diagnoses including hemiplegia, muscle wasting, obesity, muscle weakness, pain, debility, and hypokalemia, a quarterly MDS showed intact cognition for daily decision making. On 01/11/2026 at 10:25 a.m., this resident was observed lying in bed with a medication cup containing four pills left unattended on the over-bed table; the resident stated these were his morning medications that he had not taken. At 10:30 a.m., the medications were still at the bedside when observed with the LPN responsible, who acknowledged the medications should not have been left at the bedside and that she should have stayed with the resident until the medications were swallowed. The DON later confirmed the nurse should not have left the medications unattended and should have remained until they were taken. For a second resident, admitted on 12/19/2025 with diagnoses of rhabdomyolysis, acute pulmonary edema, chronic kidney disease, heart failure, and atrial flutter, a physician order dated 12/31/2025 directed Lasix 10 mg/ml, 4 ml IV twice daily for edema for three days, with one dose to be given that day and then twice daily for three days. Review of the January 2026 MAR showed no documented evidence that Lasix was administered as ordered on 01/01/2026 at 8:00 p.m., 01/02/2026 at 8:00 a.m., and 01/03/2026 at 8:00 p.m. In an interview on 01/13/2026 at 4:45 p.m., the DON and Corporate Nurse confirmed there was no documentation of Lasix administration for those ordered times. These findings demonstrate failures to ensure licensed nurses had and applied the necessary competencies and skills to administer and document medications according to physician orders and facility policy.
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