Medications Not Administered by Preparing Nurse
Penalty
Summary
A deficiency occurred when a nurse prepared medications for a resident but did not administer them herself, instead handing them to another nurse to administer. Specifically, one LPN pulled and prepared medications from the medication cart for a resident with chronic obstructive pulmonary disease, cerebral infarction, and dementia, who was dependent on staff for medication administration. The prepared medications were then given to a second LPN, who administered them to the resident. Both nurses confirmed this sequence of events during interviews. Facility policy requires that medications be administered by licensed nurses in accordance with standards of practice, and that the nurse who prepares the medications should be the one to administer them. This practice was not followed, as observed during the medication pass. The incident was identified during a review of medication administration for one resident, but it had the potential to affect all residents on the same hall.