Medication Administration Competency Deficiencies
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies and skills to administer medications as ordered for three residents. In one case, a resident with complex medical conditions, including sepsis and osteomyelitis, was given the wrong intravenous medication due to a lack of verification and proper handoff between two LPNs, one of whom was not IV certified. The medication error was not fully investigated, and required neurological assessments were not completed according to protocol, with documentation ceasing before the required monitoring period ended. Staff interviews revealed gaps in education regarding medication rights and incident response procedures. Another resident, admitted with sepsis and other serious diagnoses, did not receive all prescribed doses of an IV antibiotic due to medication unavailability and communication lapses. The MAR and progress notes showed that eight doses were missed, and documentation was inconsistent regarding physician notification and medication holds. Staff interviews confirmed difficulties in obtaining the medication and confusion about whether the full course was completed. The resident's PICC line was discontinued before the antibiotic regimen was finished, necessitating reinsertion for completion of therapy. A third resident experienced multiple medication administration errors during observation. An LPN administered a probiotic that was not the same as the one ordered, and two different eye drops were given consecutively without the recommended interval between administrations. The facility lacked a policy for eye drop administration, and staff were unclear about the equivalency of probiotics. These incidents demonstrate failures in medication verification, adherence to administration protocols, and staff competency in medication management.