Failure to Ensure Nursing Services Met Professional Standards of Quality
Penalty
Summary
Nursing services failed to meet professional standards of quality when a registered nurse (RN) delegated the administration of oral medications and the performance of fingerstick blood glucose checks to a certified nurse aide (CNA), who is not licensed to perform these tasks. The RN pulled medications and allowed the CNA to administer them to multiple residents, and also permitted the CNA to perform blood glucose monitoring. The CNA confirmed administering medications to at least two residents and performing a blood glucose check on another, while the RN acknowledged asking the CNA to perform these tasks. This delegation of duties was outside the CNA's scope of practice and not permitted by facility policy or state regulations. Additionally, during a medication pass observation, a licensed practical nurse (LPN) failed to verify the resident's name on a pharmacy supply card before preparing medication for administration. The LPN obtained torsemide tablets from a supply card labeled for a different resident and prepared to administer them to another resident. The LPN admitted to checking only the medication and dose, not the resident's name, and stated that the supply card had been misplaced in the medication cart. The unit manager confirmed that the LPN did not follow the expected procedure of verifying the correct medication, dose, and resident name. The residents involved had various medical diagnoses, including diabetes mellitus, hypertension, Parkinson's disease, major depressive disorder, atrial fibrillation, chronic pain, and vascular dementia. The facility's own documentation and staff interviews substantiated that unlicensed staff performed tasks restricted to licensed personnel, and that medication administration procedures were not properly followed, resulting in a failure to ensure nursing services met professional standards of quality.