Early Medication Administration and Incomplete Narcotic Count Documentation
Penalty
Summary
A deficiency was identified when a registered nurse administered morning medications to a resident more than two hours before the scheduled time, without ensuring the required safety parameters were met. The medications, which included blood pressure medications with specific hold parameters, were left at the resident's bedside before they were due. The nurse did not obtain or verify the resident's vital signs prior to administration, instead relying on data from a certified nurse aide whose shift had not yet started, making it impossible for the data to have been available at the time of administration. The nurse later confirmed that medications for multiple residents were given early to accommodate his work schedule. Further review revealed that the medication administration record was inaccurately documented, as the nurse recorded the medications as being given on time, despite administering them early. The facility's policy requires medications to be administered within one hour of the scheduled time and for vital signs to be obtained and recorded when applicable. The nurse's actions were inconsistent with these policies, and the nurse supervisor confirmed that this practice should not occur. Additionally, a separate deficiency was noted regarding the facility's narcotic count procedures. During a medication cart audit, it was found that the narcotic count sheet was not fully completed, with missing signatures and verification fields for both the day and afternoon shifts. The director of nursing confirmed that licensed staff are required to sign the narcotic count sheet after reconciliation, as outlined in the facility's policy. The incomplete documentation failed to ensure proper accountability and reconciliation of controlled substances.