Failure to Ensure Resident Ingested Ordered Oral Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate administration of routine medications and to observe that a resident successfully ingested ordered oral medications. The resident had multiple significant medical diagnoses, including a displaced bimalleolar fracture of the right lower leg, lack of coordination, need for assistance with personal care, muscle wasting and atrophy, unsteadiness on feet, epilepsy, dementia, hypertension, chronic congestive heart failure, and chronic kidney disease. Her MDS showed she was cognitively intact with a BIMS score of 15/15 and she had no signs or symptoms of swallowing disorders. Physician orders included Apixaban, Levetiracetam, Methocarbamol, Metoprolol Tartrate, and Sertraline, all to be given orally on specific schedules. Record review of the MAR/TAR for the month showed that the medication aide documented that he orally administered Sertraline 50 mg, Apixaban 5 mg, Levetiracetam 500 mg, Metoprolol Tartrate 25 mg, and Methocarbamol 500 mg to the resident on the evening in question. However, a progress note later that evening documented that during shift change the resident was found not responding, with drool and her p.m. medications on her face. The LVN who assessed the resident noted that the resident would start to answer questions but was unable to complete her thoughts, and that four medications were observed on the resident’s face. The DON subsequently identified the medications on the resident’s face and provided them to EMS, although staff interviewed could not clearly state which specific medications were present, only that one may have been Metoprolol and another a blue pill. Multiple staff interviews confirmed that facility policy and practice required MAs and nurses to observe residents take their medications and ensure they were successfully swallowed, consistent with the written medication administration policy that includes a checklist item to observe the resident take medications. Staff, including LVNs, the MA, the ADM, the ADON, and the Regional Nurse, all stated that MAs and nurses were responsible for administering medications according to physician orders and observing residents orally take them. The MA reported that he verified residents took their medications by talking to them after administration, and stated he had observed this resident take her medications by talking to her after giving them. Despite this, the resident was later found with four medications on her face, indicating that the medications documented as administered were not actually ingested, constituting a failure to provide and accurately administer routine medications as ordered and to follow the facility’s own medication administration guidelines.
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