Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications according to acceptable standards of nursing practice for one resident. The incident involved a Licensed Practical Nurse (LPN) allegedly leaving medications at the bedside of a resident who was cognitively intact and had multiple diagnoses, including cellulitis, hypertension, heart failure, depression, and acute kidney failure. The resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The medication in question was Tramadol, prescribed as needed for pain. On the day of the incident, a Certified Nursing Assistant (CNA) informed the resident that their medication was on the bedside table after the resident returned from a shower. The resident requested the CNA to hand them the medication, which the CNA did. The facility's investigation concluded that the LPN left the medication at the bedside, although the LPN did not recall doing so. The Assistant Director of Nursing (ADON) confirmed that the expectation was for nurses to ensure residents took their medications before leaving the room, as leaving medications unattended could pose a risk. Interviews with the Assistant Director of Nursing, the LPN, and the Director of Nursing (DON) revealed that the facility's policy was not followed, as medications should not be left unattended at a resident's bedside. The DON stated that the investigation could not confirm what medication was left at the bedside, and the resident was transferred to the hospital shortly after the incident. The facility's policy required that medications be administered in accordance with prescriber's orders and that nurses should return to administer medications if a resident is not available during the initial medication pass.
Plan Of Correction
All residents had potential to be affected. 1. Resident #1 no longer resides at the facility. The DON re-educated LPN #1 on 11.25.24 on the facility's medication administration policy including but not limited to ensuring meds are taken before leaving the resident and that medications are not left at the bedside. No further variances were noted. CNA#1 on 11.25.24 was educated to immediately notify the supervisor if medications are noted at the bedside. 2. Rounds were made on current residents on 12.3.24 by the DON with no medications noted at resident beside. On-going rounds continued. 3. Licensed Nurses were re-educated on 11.25.2024 on the facility's medication administration policy including but not limited to ensuring meds are taken before leaving the resident and that medications are not left at the bedside. Facility staff were educated on 11.25.2024 on notifying the nursing supervisor immediately if medications are noted at bedside. 4. The Director of Nurses/designee will conduct 3 rounds on each floor weekly to validate no medications are left at the bedside. Variances will be addressed. In addition, 3 medication pass competencies will be completed to validate that the medication administration process is in compliance with professional standards. These audits will be conducted weekly x 4 weeks, then monthly x 2 months. The findings of the audits will be submitted by the Administrator to the QAPI Committee for review and recommendation monthly for 3 months or ongoing until compliance is sustained.