Failure to Follow Medication Administration Protocols
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to follow proper medication administration protocols for a resident with diagnoses including Parkinson's disease, personality disorder, depressive disorder, persistent mood disorder, and hyperlipidemia. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. During a morning medication pass, the LPN prepared multiple medications and identified the resident only by checking the photograph on the medication administration record (MAR) before entering the room. The LPN placed five medication cups on the resident's bedside table and began to explain the medications, but was unable to recall the name of one medication and left the room to check, leaving the prepared medications unattended at the bedside. Upon returning, the LPN administered the medications without using a second identifier to verify the resident's identity, such as asking for the resident's name or date of birth, or checking an armband. The LPN did not call the resident by name or use any other form of secondary identification, contrary to facility policy and standard practice. The LPN later acknowledged not using two identifiers and leaving medications unattended, and was unable to recall all five rights of medication administration. Facility leadership confirmed that the expectation was to use two forms of identification and not to leave medications unattended, as outlined in the facility's medication administration policy.