Failure to Follow Professional Standards for Medication Preparation and Administration
Penalty
Summary
A deficiency was identified when a medication cart was observed to contain an unlabeled medication cup with pills, including three unidentifiable pills, in the top drawer. The cup was tipped on its side, and the pills were not secured. Staff interviews confirmed that the medication cup was intended for a specific resident, and that the medications had been prepared by the night nurse but were administered by a different nurse on the day shift. The day shift nurse did not prepare the medications themselves, contrary to professional standards and facility policy, which require that nurses only administer medications they have prepared. Further review revealed that the medications included controlled substances such as Oxycodone, which was not double locked as required. The facility's policy explicitly prohibits pre-pouring medications and mandates that administration and documentation occur at the time of the medication pass. The night nurse admitted to preparing the medications in advance and leaving them in the cart for the day nurse to administer, resulting in a failure to follow both professional standards and facility policy for medication storage and administration.