Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice for two residents. An LPN was observed preparing medication cups for two different residents at the same time, stacking the cups on the medication cart, and only including packaged medications while omitting floor stock medications. The LPN stated that this was done to save time and acknowledged that it did not align with the facility's medication administration policy. Upon inspection, it was found that neither resident had all of their prescribed 9:00 AM medications in their respective cups, with several medications missing for both residents. Interviews with the nurse manager and the DON confirmed that the facility's policy requires preparing and administering medications for one resident at a time, immediately prior to administration, and then signing them out. Both staff members expressed that the observed practice was unsafe and not in accordance with professional standards or facility policy. The facility's policy, last revised in October 2023, specifically states that medications are to be administered in an accurate, safe, timely, and sanitary manner, and that safe preparation practices must be followed.