Failure to Ensure Medication Administration Met Professional Standards
Penalty
Summary
During a medication pass observation, an LPN prepared morning medications for one resident, which included potassium, a multivitamin, Cinacalcet, vitamin D, amlodipine, clonazepam, and hydrocortisone. After preparing the medications and placing them in a plastic cup, the LPN locked the cup in the medication cart to retrieve a glucometer. Upon returning, the LPN took a medication cup from the cart and administered the medications to the resident in the bed closest to the door, giving approximately half the medications at a time. The LPN then checked the resident's blood sugar and documented the administration in the Medication Administration Record (MAR). A subsequent review revealed that the resident who received the medications was not the intended recipient for whom the medications were prepared. The LPN had previously set up medications for another resident and, upon returning to the cart, mistakenly administered those medications instead. The LPN did not inform the surveyor of the switch during the observation. Facility policy required adherence to the five rights of medication administration and specified that medications should be administered at the time they are prepared and not pre-poured. The LPN had completed orientation to the medication pass routine prior to the incident.