Failure to Follow Professional Standards in Medication Reconciliation and Administration
Penalty
Summary
Staff failed to consistently follow nursing professional standards for two residents, resulting in medication reconciliation and administration errors. For one resident with multiple fractures, heart conditions, and recent surgeries, observations revealed that scheduled morning medications and as-needed pain medications were not administered at the ordered times. The resident reported significant pain and had not received any morning medications by late morning. Interviews with LPNs confirmed that medication passes were running late, and this was a regular occurrence due to insufficient staffing. Review of the electronic medical record and narcotic disposition book showed discrepancies in documentation, with pain medications not recorded as administered in the electronic system, though they were documented in the narcotic log. For another resident admitted for rehabilitation after a spinal cord injury and surgery, the facility failed to properly reconcile medication orders upon admission. The hospital discharge summary specified that Oxycodone should be administered as needed, but the medication was entered into the facility's system as a scheduled dose every four hours. As a result, nursing staff administered Oxycodone every four hours regardless of the resident's reported pain level, including when the resident reported no pain. The error persisted until it was identified during a review, and the order was not corrected to match the physician's intent for as-needed administration. Interviews with the unit manager, medical director, and DON confirmed that the medication reconciliation process was not properly followed, and nursing staff did not compare the physician's orders with the pharmacy label and the medication administration record. The facility's policy required licensed nurses to verify the accuracy and frequency of medication orders, but this was not done, leading to inappropriate medication administration and documentation errors for both residents.