Unlicensed Staff Administered Medications on Midnight Shift
Penalty
Summary
The facility failed to ensure that only licensed and qualified personnel administered medications according to each resident's written plan of care for five memory care residents during the midnight shift. Multiple residents with diagnoses including dementia, hypothyroidism, psychotic disorder, and severe intellectual disabilities received medications that were prepared, poured, and administered by an unlicensed staff member, specifically a CNA, rather than a licensed nurse as required by facility policy and physician orders. Medication administration records showed that medications such as Levothyroxine, Omeprazole, and Carbidopa-Levodopa were signed out under the name of an LPN, but were actually administered by the CNA using the LPN's login credentials. The incident occurred when the assigned LPN on the 100 unit experienced a medical emergency and left the facility, leaving the medication cart keys with a CNA. The CNA contacted the on-call scheduler and was later told that another LPN from a different unit would oversee the 100 unit. The CNA then obtained the LPN's login credentials and proceeded to administer medications to five residents, documenting the administration under the LPN's name. The LPN in question denied providing her credentials, but the CNA's statement and camera footage confirmed that the CNA prepared, poured, and administered the medications. The residents involved were not cognitively intact for daily decision-making, as indicated by their Minimum Data Set (MDS) assessments, and required medications to be administered by licensed personnel according to physician orders. The facility's policy stated that only persons legally authorized could administer medications, but this policy was not followed during the incident. The Director of Nursing confirmed that no staff, including the scheduler, notified her of the situation, and the deficiency was identified through review of records, staff statements, and video evidence.