Failure to Follow Safe Medication Administration Procedures
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow proper medication administration procedures for a resident with schizophrenia, hypertension, and dysphagia, who also had moderate cognitive impairment and lacked capacity for medical decision-making. The LVN prepared the resident's morning medications without properly identifying the resident, as the resident was not present during medication preparation and the LVN was unable to confirm the resident's location or identity at the time. The LVN removed medications from multiple bubble packs, placed them in a cup, and subsequently crushed three tablets and opened a capsule, mixing all the medications together in applesauce. This was done without a physician's order to crush the medications, and the LVN was unable to verbalize which medications were being administered or the reasons for not crushing certain medications together. The LVN admitted to not reviewing physician orders or verifying the medications with the resident prior to administration. The Registered Nurse Supervisor confirmed that there was no physician's order to crush the medications and that the LVN did not follow required procedures for resident identification, medication verification, or safe medication administration. Facility policies reviewed indicated that medications should only be crushed if ordered, residents must be identified before administration, and medications should be administered at the time they are prepared, none of which were followed in this instance.