Failure to Communicate Nursing Assignment Results in Delayed Medication Administration
Penalty
Summary
The facility failed to establish and communicate which licensed nurse was responsible for providing care to a resident during the evening shift. On the specified date, there was confusion among the nursing staff regarding the assignment of care for the resident. Although the monthly nursing assignment indicated that one LVN was scheduled to provide care, it was requested that this nurse not care for the resident, and another LVN was supposed to assume responsibility. However, this change was not communicated to the replacement nurse, resulting in a lack of clarity about who was responsible for the resident's care during that shift. As a result of this miscommunication, the resident did not receive scheduled medications, including lactobacillus, metformin, metoprolol, and insulin lispro, at the appropriate times. The insulin was administered almost two hours late by the nurse supervisor, and the administration times for the other medications were not documented. The resident had multiple diagnoses, including dementia, diabetes mellitus, hypertensive heart disease, and heart failure, which required timely medication administration. The facility's policies required medications to be administered within one hour before or after the scheduled time, which was not followed in this instance.