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Based on review of documentation and interview, it was determined that Highland Rehabilitation Hospital nursing staff did not always distribute medications in accordance with nursing standards of care.

Findings were:

According to a family member, on January 20, 2017, Patient # 1 refused his evening medications. The nurse (Staff member # 5, RN) asked his wife to assist with the medications. Per the wife, the nurse "Left me with a pill in his mouth and one in the cup and walked out."

Nursing note dated 1/20/17 read in part "Refusing to take meds from staff. Meds given to wife to encourage patient to take them. More cooperative with wife ..."

There was no documented evidence to suggest that Staff member # 5 watched the patient take his medications. An attempt was made to reach the nurse for interview but she was unavailable.

In an interview with the Chief Nursing Office on 5/10/17, it was agreed that the nurse's documentation was incomplete regarding patient ingestion of the medication. If the nurse left the medication with the patient's wife without seeing him actually swallowing it, then that was poor nursing practice.