Failure to Ensure Nursing Staff Competency Leads to Medication Mismanagement
Penalty
Summary
The facility failed to ensure that all licensed nursing staff maintained the necessary competencies and skills to provide appropriate care to residents, resulting in mismanagement of controlled substances and improper medication administration. During medication administration, a registered nurse (RN) was observed handling medications that were not labeled with resident names and preparing them in advance, contrary to facility policy. The RN also demonstrated a lack of knowledge regarding insulin injection sites and the operation of IV medication administration, as evidenced by her inability to explain the process or duration for a resident's IV antibiotic therapy. Further review revealed that the RN administered a controlled substance, Tramadol, to a resident without proper documentation or verification of orders, and took the medication from another resident's supply. The RN failed to document the administration of controlled substances on the required inventory sheets, instead recording them on a piece of paper with the intention to update records later. Discrepancies were found between the number of doses signed out and those actually administered, and the RN could not provide clear explanations for these actions during interviews. The investigation also uncovered that the facility did not have a process in place for ongoing competency evaluations of licensed nursing staff after orientation. The staff development educator confirmed that only certified nursing assistants received competency evaluations, and there was no system to ensure that licensed nurses remained competent in their roles. This lack of oversight contributed to the observed deficiencies in medication management and resident care.