Improper Medication Administration to Visitor Instead of Resident
Penalty
Summary
A medication administration deficiency occurred when an LPN failed to properly identify and administer medications to the correct individual and did not remain with the resident until medications were taken. The resident involved had been admitted with diagnoses including diabetes, other cirrhosis of the liver, and heart failure, was cognitively intact, and required assistance with activities of daily living. On the morning in question, the resident’s sister was lying in the resident’s bed while the resident was not in the room. The LPN entered to administer the resident’s scheduled morning medications, which included Metformin, Tamsulosin (Flomax), Lactulose, spironolactone, and house liquid protein, and left the medications with the sister after she stated she would ensure the resident took them upon returning. Shortly thereafter, the sister independently contacted 911 and was transported to the hospital after consuming the medications that had been left in the room. The resident later reported that upon returning from the dining room, the sister informed them she had taken the medications and was feeling dizzy, leading her to call 911. The facility’s documentation and the February MAR showed that the medications were documented as administered to the resident at the scheduled time. The DON stated that the nurse should have followed the facility’s medication administration policy, including the rights of medication administration and remaining with the resident until medication administration was complete.
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