Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to pharmaceutical procedures 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. Both instances were confirmed through interviews with the involved staff members, who admitted to signing off medications prematurely. The LPNs involved provided explanations for their actions. One LPN stated that she was not informed that signing off medications before administration was not allowed and did so to familiarize herself with the resident's medication. The other LPN mentioned that he signed off on the medication early because it was only one medication being administered via a tube. The Director of Nursing confirmed that all nurses had received training on medication administration policies, which clearly state that medications should only be signed off as given after they are administered.
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 on 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.