Failure to Ensure Proper Medication Administration by Nursing Staff
Penalty
Summary
Nursing staff failed to follow professional standards of medication administration for one resident. Observation revealed that the North Unit Nurse Manager prepared a cup of 14 medications for a resident and then handed the cup to an LPN, who subsequently administered the medications to the resident. The LPN had been away from the medication preparation area during the process, retrieving a nutrition supplement, and did not personally prepare the medications. The facility's policy and LPN job description indicated that LPNs are expected to administer only medications they have personally prepared and not to leave medications at the bedside without an order. Multiple staff interviews confirmed that it was not acceptable practice to prepare medications and have another nurse administer them, citing safety concerns and lack of knowledge about the contents of the medication cup. The DON and interim Administrator both stated their expectation that staff should prepare and administer medications individually, and not hand off medications to another staff member for administration. The facility's policy did not provide specific guidelines for situations where more than one nurse is involved in medication administration for a single resident.