Failure to Ensure Staff Competency in Medication Administration
Penalty
Summary
The facility failed to ensure that licensed staff, including nurses and medication aides, demonstrated the necessary competencies and skill sets required to safely administer medications according to physician orders. Specifically, three staff members were found to have administered antihypertensive medications to residents even when their blood pressure readings were outside the parameters specified in the physician's orders. Documentation on the Medication Administration Records (MARs) confirmed that medications were given despite blood pressure readings below the required thresholds, and staff interviews corroborated that these medications were administered inappropriately. Multiple residents with complex medical histories, including diagnoses such as cerebral palsy, epilepsy, hypertension, chronic obstructive pulmonary disease, and end-stage heart failure, were affected by these actions. For example, one resident with severe cognitive impairment and hypertension received metoprolol on several occasions when her blood pressure was below the ordered parameters. Similar incidents occurred with other residents who had orders for blood pressure medications to be held if their readings were too low, yet the medications were still administered by staff. Interviews with staff and administration revealed a lack of current competency checks for nurses and medication aides. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that competency checks had not been completed under the current company, and there was no accountability system in place to monitor proper medication administration. Review of facility policies and the facility assessment indicated that staff competency should be regularly evaluated and documented, but these requirements were not met, as evidenced by missing or outdated competency records.