Failure to Follow Professional Standards During Medication Administration
Penalty
Summary
The facility failed to follow professional standards of practice during medication administration for two residents, resulting in inaccurate documentation, late or missed medications, and the potential for worsening medical conditions. For one resident with a history of blood infection requiring IV antibiotics, the nurse was unsure if the IV medication had been administered as scheduled. During observation, the nurse prepared both IV and oral medications, but several medications were signed out as administered before they were actually given. Some medications were not observed being administered at all, and others were documented as not given without explanation. The IV medication was left attached to the resident for longer than ordered, and the nurse was unable to explain the proper administration process. Additionally, the nurse reported administering a controlled pain medication after the scheduled time but could not verify or properly document this, and it was later discovered that the medication may have been taken from another resident's supply. For the second resident, the nurse was observed retrieving unlabeled medications from the medication cart that had been pulled earlier and stored together, rather than preparing them immediately prior to administration as required by policy. The nurse administered a group of oral medications and insulin more than an hour after the scheduled time, and some ordered medications were not observed being given at all. The nurse also made a verbal error regarding the injection site for insulin. Review of physician orders and the medication administration record confirmed that several medications were not administered within the required timeframe, and some were not administered at all during the observed medication pass. Facility policy requires medications to be prepared immediately prior to administration, prohibits administering medications from one resident's supply to another, and mandates that medications be administered within 60 minutes of the scheduled time. Documentation is to occur immediately after administration, not before. The observed practices deviated from these standards, resulting in inaccurate records, late or missed doses, and improper handling of controlled substances.