Failure to Administer Ordered Bedtime Medications After Staff–Resident Altercation
Penalty
Summary
Facility staff failed to ensure that significant medications were administered as ordered for one resident. The facility’s medication administration policy required staff to verify the correct medication, dose, route, rate, time, and resident with each administration. The resident, who had a history of falls, diabetes, and hypertension, had care plans directing staff to administer medications per physician orders. Review of the January MAR showed that on the evening shift of 1/6/26, the resident did not receive ordered doses of Seroquel 150 mg, Atorvastatin 10 mg at bedtime, and Lantus Solostar 28 units subcutaneously at bedtime. These medications were documented in the MAR by an agency RN as not administered due to resident refusal. Subsequent documentation and interviews conflicted with the refusal notation. A clinical progress note the next day recorded that the resident approached staff and reported not receiving his scheduled medications for the 3–11 p.m. shift. Facility investigation statements indicated that during the shift, the agency RN and the resident had a verbal altercation after the RN told the resident he was not permitted in the kitchenette, and the RN supervisor intervened. The RN supervisor reported offering to pass the resident’s medications, but the agency RN refused this assistance. Another staff statement indicated the agency RN asked another nurse or the RN supervisor to give the medications because the resident was being rude, but nursing staff refused to assist. The agency RN stated she intended to have another nurse witness medication administration when the resident returned to the unit, but documented that the resident left and did not return until early morning. In a later interview, the resident stated the nurse was not around between approximately 8 and 9 p.m., that he went to his room and did not receive his medications, and that he did not leave the facility until about 1 a.m., and reported having no ill effects.
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