Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
Nursing staff failed to follow professional standards of practice during medication administration for two residents. In one instance, a nurse prepared a medication card labeled Metoprolol Succinate ER 50 mg for a resident, while the Medication Administration Record (MAR) listed Metoprolol Tartrate 50 mg. The nurse identified the discrepancy between the medication card and the MAR at the time of administration, did not administer the medication, and stated she would follow up on the issue. Upon further review, the nurse confirmed that although the resident had been receiving the correct medication and dose, the order was not clarified when written and was incorrectly transcribed as tartrate instead of succinate on the MAR. In another instance, a nurse prepared an insulin pen for a different resident and was observed holding the pen horizontally instead of upright while priming it, contrary to the manufacturer's instructions. Administrative staff confirmed that nursing staff are expected to clarify medication orders when discrepancies arise. These actions demonstrate a failure to clarify, accurately transcribe, and reconcile new physician's orders, as well as a failure to follow proper technique for insulin administration.