Unlicensed Personnel Administered Medications and Performed Blood Sugar Checks
Penalty
Summary
The facility failed to ensure that only appropriately licensed personnel administered medications and performed blood sugar checks for residents. According to the facility's own policy, only individuals licensed or permitted by the state are allowed to prepare, administer, and document medication administration. However, a certified nurse aide (CNA), who was also a nursing student but not yet licensed or certified as a medication technician, was permitted by the Director of Nursing (DON) to administer medications and perform blood sugar checks for multiple residents. The CNA was observed by residents and staff administering medications and conducting blood glucose monitoring without direct supervision in resident rooms. Interviews revealed that the DON called the CNA to the facility specifically to allow the CNA to practice medication administration and blood sugar checks, despite the CNA not having completed the required clinical check-offs or holding the necessary certification. The DON and a registered nurse (RN) prepared medications and provided them to the CNA, who then administered them to residents. The DON initially observed and assisted the CNA but later left the facility, leaving the RN to oversee the CNA. The CNA administered medications to 22 residents and performed blood sugar checks on three residents during a single shift, including scanning continuous glucose monitoring (CGM) systems and documenting readings in the medication administration record (MAR). Other staff, including a certified medication technician (CMT), LPN, and RN, confirmed that medication administration and blood sugar checks were not within a CNA's scope of practice and that only nurses or CMTs should perform these tasks. The administrator also acknowledged that CNAs should not administer medications or perform blood sugar checks or CGM scans. The facility's failure to adhere to its own policy and state regulations resulted in unlicensed personnel administering medications and performing clinical tasks reserved for licensed staff.