Failure to Ensure Staff Competency and Accurate Medication Administration
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies to care for residents, as evidenced by the lack of completed annual performance evaluations and skills competencies for all eight reviewed employees. Employee files revealed missing or outdated documentation, including annual physicals, tuberculosis (TB) skin tests, background checks, abuse training, and skills competencies. The Director of Staff Development confirmed that these requirements were not met and acknowledged that all necessary documents should be maintained in employee files and be readily accessible. Licensed nurses did not identify a discrepancy between the medication on hand and the medication ordered by the medical doctor for a resident. Specifically, the Medication Administration Record (MAR) indicated an order for Polyethylene Glycol 1450, while the medication available was Polyethylene Glycol 3350. Nurses failed to recognize and address this difference, and it was confirmed that the facility only stocked the 3350 formulation. The Interim Director of Nursing stated that nurses are expected to clarify such discrepancies with the physician but this was not done. Additionally, three sampled Licensed Vocational Nurses (LVNs) were unable to correctly perform basic nursing dosage calculation conversions, such as converting ounces to milliliters and tablespoons to milliliters. One nurse was observed administering medication to a resident without using proper measuring tools, instead using a plastic spoon and failing to measure the correct amounts as ordered by the physician. Both residents involved had severe cognitive impairment and were completely dependent on staff for care, with complex medical histories including neuromuscular dysfunction, tracheostomy, and atherosclerotic heart disease.