Improper IV Medication Administration by LPN
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of clinical quality and practice, specifically in the administration of intravenous medication. This deficiency was identified during a recertification survey, where it was observed that an LPN administered intravenous antibiotics through a Peripherally Inserted Central Catheter (PICC) to a resident, despite facility policy prohibiting LPNs from performing such tasks. The resident in question had severely impaired cognition and required intravenous medication administration. The LPN, who had been employed for only one month, was not aware that the intravenous line was a central catheter and had not been adequately in-serviced on intravenous administration. Interviews with facility staff revealed a lack of proper communication and oversight regarding the administration of medications through central lines. The unit supervisor and the Assistant Director of Nursing acknowledged that LPNs are not permitted to administer medications through a central line and that there was a failure in ensuring that the LPN was properly trained and supervised. The Director of Nursing also indicated that there should have been more effective monitoring and communication to prevent such an incident. The deficiency highlights a breakdown in the facility's processes for ensuring compliance with medication administration protocols.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? ò Resident # 389 had no negative outcomes from the deficient practice. IV medication via Central line was administered by RN after 2/6/2025. Licensed Practical Nurse # 2 was in-serviced on the “Administering Medications by Central Line Access” policy and procedure on 2/6/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? ò All residents receiving intravenous medications have the potential to be affected by this practice. All residents’ medication administration records who are currently receiving intravenous medications/ Fluids/Flush were reviewed, no outstanding issues were found. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: ò The facility Policy and Procedure titled “Administering medications by Central Line Access” was reviewed, no revision required. All nurses are being in-serviced on the above policy and procedure with an emphasis on the professional scope of practice of LPN. Education on administration of medications by central line access was added to the orientation and to the annual in-services. A new process of marking administration by RN only for medications administered via central lines is being implemented to ensure the scope of practice is being maintained. The audit tool was created to ensure compliance. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? ò On a weekly basis for the first quarter, the Director of Nursing, or designee, will audit the intravenous medication(s) order and Medication Administration Record [REDACTED]. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, Director of Nursing will report the findings to the Administrator. On a quarterly basis, Director of Nursing will report findings to QAPI Committee. QAPI Committee to determine if further action is required. 5. The title of the person responsible for correction of each deficiency: Director of Nursing & Assistant Director of Nursing.