Failure to Accurately Administer and Document IV Medications
Penalty
Summary
Licensed staff at the facility failed to implement physician orders and adhere to professional standards of nursing practice in the administration and documentation of intravenous (IV) medications for a resident with diagnoses including vascular dementia and cerebral infarction. Over a period of time, staff documented the administration of Zosyn and Daptomycin IV antibiotics in the resident's medical record inaccurately. Specifically, there were multiple instances where doses were documented as administered days after the scheduled time, and in some cases, by staff who were not present or qualified to administer the medication. For example, a registered nurse and the former director of nursing documented doses as given on dates when they were not clocked in, and a licensed practical nurse documented administration of IV medications despite not being qualified or having actually administered them. The facility's own policies and the Alabama Board of Nursing standards require that medications be administered and documented at the time of administration, with any late entries clearly identified as such. However, the electronic medication administration records (EMAR) and audit reports revealed that documentation was not timely, accurate, or consistent with these standards. Some entries lacked the required date and time, and there was no proper use of late entry documentation. Interviews with staff confirmed that some documentation was made in error, and staff did not always follow the facility's policy for correcting such errors. Additionally, the facility's medication inventory did not match the number of doses documented as administered, raising further concerns about the accuracy of medication administration and documentation. These failures were identified through interviews, record reviews, and policy analysis, and were determined to have caused, or were likely to cause, serious injury, harm, impairment, or death to residents. The deficiency was cited under F658 for failure to ensure services provided met professional standards of quality, specifically in the area of comprehensive resident-centered care planning and medication administration documentation.