Failure to Accurately Document and Administer IV Medication
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) signed out an intravenous (IV) medication, Vancomycin HCL, as administered to a resident, but did not actually give the medication. The resident, who had a peripherally inserted central catheter (PICC) and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported not receiving the IV medication at the time it was documented as given. The Medication Administration Record (MAR) and Medication Administration Audit Record (MAAR) both indicated that the medication was administered at 10:01 am, but the resident stated at 1:00 pm that the medication had not been received. The LPN confirmed during an interview that the medication was signed out but not administered, and acknowledged that medications should only be signed out after they are given to prevent errors. The Director of Nursing (DON) also stated that facility policy requires medications to be signed out immediately after administration, and not before. The facility's policies and job descriptions for both LPNs and RNs specify that medications must be administered and recorded in accordance with physician orders and regulatory requirements. The failure to follow these procedures resulted in inaccurate documentation and a failure to meet professional standards of quality for medication administration.