Failure to Secure, Label, and Properly Administer Medications
Penalty
Summary
The deficiency involves failure to secure and properly label medications and to ensure medications are administered in accordance with facility policy. During early morning medication passes, a registered nurse repeatedly left a medication cart unlocked and unattended while administering medications to multiple residents, despite the facility’s Medication Storage Policy requiring medication carts to be locked when not attended by authorized personnel. The DON confirmed that all medications should be locked in the medication cart so that only nurses have access. In a separate observation of another medication cart, a surveyor and a registered nurse found a medication cup containing seven unlabeled tablets, with only “250mg Vit C” written on the cup and no other means to identify the tablets. The nurse stated she had not used that cart during her shift, could not identify the medications, and acknowledged that medications should be labeled. Another deficiency was identified when a medicine cup containing four different colored pills was found on a resident’s bedside table during unit rounds. The assigned RN stated she had been pulled away to another resident and did not intend to leave the pills at the bedside, while the resident reported that this nurse leaves medications with her all the time. The DON stated that nurses are required to remain with residents for the duration of medication administration to ensure medications are completely taken and that she was not aware of any resident in the facility authorized to self-administer medications. The resident’s order summary showed diagnoses including unspecified dementia, anxiety disorder, and depression, and indicated that only specific items (PreserVision AREDS and TheraBreath Oral Rinse) may be left at the bedside for self-administration. The facility’s Medication Administration policy requires staff to remain with the resident to ensure the resident swallows the medication.
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