Unqualified Staff Administered Medications
Penalty
Summary
The facility failed to ensure that only qualified staff administered medications to residents, as required by state regulations and facility policy. Specifically, a staffing coordinator posted a request for Certified Medication Aides (CMAs) to pass medications, but an agency medical assistant, who was not a CMA and not permitted by Oregon law to administer medications in a nursing facility, signed up for the shift and administered medications on two floors. The error was discovered only at the end of the shift when nursing staff questioned the individual's qualifications and verified her credentials, revealing she was a medical assistant, not a CMA. The facility's policy stated that only licensed or state-permitted individuals could prepare, administer, and document medication administration. Despite this, the medical assistant worked an entire eight-hour shift administering medications under the mistaken belief that she was allowed to do so if supervised by a nurse or physician. The incident was triggered by a public complaint and confirmed through staff interviews and record review, establishing that unqualified personnel had administered medications to residents.