Failure to Follow Medication Administration Standards and Resident Identification
Penalty
Summary
The facility failed to ensure that medication administration services met professional standards of quality for two residents. Facility policy titled "Administering Medications" required that medications be administered safely and timely as prescribed, and that the individual administering medications verify the resident's identity before giving medications. Resident 1 had diagnoses including COPD and hypotension, and Resident 4 had diagnoses including respiratory failure and atrial fibrillation. An incident report documented that on an evening shift, an LPN (Employee 4), who was an agency-contracted nurse, brought medications for both Resident 1 and Resident 4 into their shared room, placed the medications on the bedside tables, and left without verifying each resident's identity at the time of administration. According to the incident report, Resident 4 noticed a pink and white pill among the medications and stated that those were not her medications. Resident 1 then stated that she takes a pink and white pill. The residents called the nurse back into the room, at which point the LPN realized that the medications had been given to the wrong residents. The Director of Nursing later confirmed that the two residents did not actually take each other's medications. The deficiency centers on the LPN's failure to follow the facility's medication administration policy, specifically the requirement to verify resident identity before administering medications, resulting in a medication error involving two residents with significant cardiopulmonary diagnoses.
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