Medications Left at Bedside and Inaccurate MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate documentation and safe administration of medications. Facility policy stated that nurses must use acceptable nursing practices when administering medications, never leave medications in a resident’s room without a physician’s order to leave them at bedside, and remain with the resident until medications are taken or remove them if refused. Despite this, staff left a full morning medication pass at a cognitively intact resident’s bedside without a physician’s order and documented the medications as administered on the MAR by a staff member who did not actually give them. The resident involved had multiple diagnoses, including COPD, Parkinson’s disease, type II diabetes mellitus, borderline personality disorder, PTSD, ADHD, bipolar disorder, hypertension, and bladder dysfunction, and had active orders for several scheduled oral medications during the morning med pass, including pantoprazole, Mag 64, ondansetron, a multivitamin, Lipitor, bethanechol, aspirin, and amlodipine. On the date of the incident, a CMT signed these medications out on the MAR but asked an LPN to deliver them. The LPN entered the resident’s room, woke the resident, and informed the resident that the medications were present. When the resident requested milk and stated he or she would take the medications if milk was provided, the LPN left the medications at the bedside, obtained milk, returned, placed a straw in the milk carton, and then left the room without observing the resident take the medications. Later that morning, the resident reported that the morning medications were missing and requested to speak with the Administrator. A CNA responded to the call light and was told by the resident that medications had been delivered while the resident was awake, that the resident then fell asleep, and that upon waking for breakfast the medications were missing. The LPN was notified of the alleged missing medications. A subsequent progress note documented that the resident later located the pills next to him or her and apologized to the LPN. In interviews, the resident stated that staff do not stay to observe medication administration despite being asked, and that on the day in question the LPN initially claimed the medications had been taken until the resident later found them in the bed. The CMT, LPN, ADON, and Administrator all acknowledged in interviews that medications should not be left at the bedside without a physician’s order and that the resident did not have such an order, confirming that facility policy was not followed and that the staff member who signed the MAR was not the one who actually delivered and observed administration of the medications.
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