Failure to Maintain Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that a licensed practical nurse (LPN) maintained professional standards of quality care in accordance with the Pennsylvania Code Title 49 Professional and Vocational standards. This deficiency was identified during a review of clinical records, facility policies, and interviews with residents and staff. Specifically, the LPN did not follow the facility's established policies and procedures regarding medication administration for one of the five residents sampled. The resident involved had a history of diplopia, bilateral cataract, and diabetes mellitus with complications related to the eyes. A physician's order required the administration of Natural Balance Tears ophthalmic solution into both eyes every six hours as needed. On November 26, 2024, the resident reported experiencing a burning sensation in the eyes after receiving medication. It was discovered that Debrox ear drops were mistakenly administered into the resident's eyes instead of the prescribed eye drops. The LPN acknowledged the error but failed to report it to the Director of Nursing (DON) or the resident's provider, as required by the facility's policy on medication errors. The DON confirmed that the medication error was not reported at the time it was identified, which was a breach of the facility's resident care policies and nursing services standards.
Plan Of Correction
Resident 1's attending physician was notified of a medication error. Resident 1 was monitored and treated following physician notification of the medication error. The resident was seen by an eye doctor. Disciplinary action was taken with the nurse due to failure to immediately report the medication error. The DON/designee will review all residents with orders for eye drops and conduct a medication pass observation with all residents receiving eye drops to identify any residents at risk. Education was provided to LPN/RN nursing staff on policy and procedure for medication administration and reporting medication errors. Attending physicians will be notified of each, if any, incorrect medication order. The DON/designee have reviewed policy and procedures for medication administration and notification of medication error with LPN/RN staff. The DON/designee will continue staff education on policy and procedures. The DON/designee will perform two medication pass observations weekly for 4 weeks, and then monthly for 2 months. Any and all negative findings will be corrected at the time of discovery, and disciplinary action will be taken as needed. All findings will be reviewed at QAPI for 6 months.