Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to pharmaceutical procedures and policies during medication administration for two residents. During an observation at 8:00 AM, an LPN was seen signing off medications for a resident before they were actually administered. Similarly, at 9:50 AM, another LPN signed off on a medication for a different resident prior to its administration. These actions were contrary to the facility's policy, which mandates that medications should only be signed off as given after they have been administered to the residents. Interviews with the involved staff revealed a lack of awareness and understanding of the correct procedures. The first LPN admitted to signing off on medications ahead of time to familiarize herself with the resident's medication regimen, indicating a misunderstanding of the proper protocol. The second LPN justified his premature signing off by stating it was only one medication being administered via a tube, suggesting a possible underestimation of the importance of following the correct procedure regardless of the situation. The Director of Nursing confirmed that all nurses had received in-service training on medication administration, yet acknowledged the need for re-education on the correct procedures. The facility's policy clearly states that staff should comply with applicable laws and the state operations manual when administering medications, highlighting a gap between policy and practice in this instance.
Plan Of Correction
Staff nurse A and B were immediately reeducated during the survey on pharmaceutical procedure and the facility's policy during medication administration and on signing the Medication Administration Record after administration of medication. Residents #4 and #50 are receiving medications as ordered according to pharmaceutical procedure and the facility's policy and have exhibited no negative outcome. An audit was conducted of current residents by the Director of Clinical Services to ensure that medications were administered prior to the administration record being signed. No issues were identified. Staff nurse A and B were immediately reeducated during the survey by the Director of Clinical Services on pharmaceutical procedure and the facility's policy during medication administration. Licensed Nurses were reeducated starting by the Director of Clinical Services on pharmaceutical procedure and the facility's policy during medication administration and not signing the medication record until medications have been administered. The Director of Clinical Services or Designee will conduct random audits of the medication administration record for 10 residents to determine if the medication administration record was signed prior to the administration of medication, daily x 4 then weekly for 4 weeks, then quarterly x 4. Findings of audits will be presented at the monthly QAPI meeting to ensure ongoing compliance.