Failure to Follow Medication Administration Policies and Resident Identification Procedures
Penalty
Summary
The facility failed to meet professional standards of quality by not following its own policy and procedure for administering medications to two of nine sampled residents. Licensed Vocational Nurses (LVN) 1 and 3 used only one resident identifier, specifically the resident's name, prior to administering medications, instead of the required two or more identifiers such as checking the wrist band and photograph. This was observed during medication administration to residents who were non-verbal or cognitively impaired, and both LVNs acknowledged during interviews that they did not follow the full identification protocol as outlined in facility policy. Additionally, LVN 1 documented in the Electronic Medication Administration Record (EMAR) that an inhaler medication was administered to a resident when, in fact, it was not given. This was confirmed during observation and interview, where LVN 1 admitted to signing off on the medication without actually administering it, stating that it was forgotten during the medication pass. The facility's policy requires that medications be documented as given only after actual administration. The residents involved included individuals with significant medical conditions such as dementia, gastrostomy status, hypothyroidism, and a need for medications like insulin and inhalers. The failure to properly identify residents and accurately document medication administration was confirmed through observation, interviews with staff, and review of facility policies and resident records.