Failure to Administer Medications as Ordered and to Observe Ingestion
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered by the physician and in accordance with facility policy, resulting in a medication error rate of 40% (12 errors out of 30 opportunities) during a medication pass observation. For one resident, a registered nurse prepared and administered a chewable aspirin 81 mg tablet in the morning, despite the physician’s order specifying aspirin enteric coated delayed-release 81 mg once daily for heart health. The Director of Nursing later confirmed that chewable aspirin should not be given when the order is for enteric-coated aspirin. For another resident, an LPN prepared 11 oral morning medications and placed the medication cup on the resident’s breakfast tray while the resident was seated in a chair with breakfast at the overbed table. The LPN then administered the resident’s insulin, left the room, documented the medications as administered in the computer, and moved the medication cart to another area of the building without observing the resident take the medications. Several minutes later, the medications remained on the breakfast tray, and the resident stated she needed to eat before taking them. There was no physician order authorizing this resident to self-administer medications. The Director of Nursing stated that a complete medication pass includes preparing medications, bringing them to the resident, and watching the resident take them, and that medications should not be left at the bedside for residents to take on their own. The facility’s policy requires medications to be administered per physician orders with verification of the right medication, dose, route, time, and resident identity.
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